(1) Good morning/ afternoon This year, the EMCDDA’s annual analysis of the drug situation is presented in a new format. The European Drug Report (EDR) 2013 consists of a set of interlinked products, and aims to provide a common entry point to the work of the EMCDDA and allow different audiences easy access to the specific information they require. It provides an analysis that is more timely (6 months earlier than earlier reports), is more graphics-based and interactive. Note to speaker, see both 2013 news releases The European Monitoring Centre for Drugs and Drug Addiction is based in Lisbon and, with the help of a network of national focal points, collects drug-related information in the 27 EU Member States, Croatia, Turkey and Norway. The agency monitors, not only drug use in Europe, but also drug-related problems, such as HIV infections and overdoses, drug markets (including the appearance of new drugs), national drug policies and drug laws, and drug-related responses developed by Member States, including prevention, treatment, harm reduction and social reintegration.

Lo scenario Europeo in materia di stupefacenti 2013 Dopo 30+ di predominio dell’eroina ci sono segni di riduzione nel consumo e offerta L’uso di altre ‘vecchie droghe’ è in generale stabile con qualche nuovo sviluppo Il mercato delle nuove droghe psicoattive è in rapida espansione (5) It is now my pleasure to present to you some of the main findings from our 2013 European Drug Report. I would like to begin by setting the scene. The major features of the European drug landscape have remained relatively stable in recent years. Drug use remains high by historical standards, but after 30+ years with heroin, in particular heroin injection, centre stage in Europe — there are now clear signs of a decline. We also note that for many other established drugs, including cannabis, cocaine and amphetamine, the overall European trends are relatively stable, and in some cases declining. Of course for all drugs we must be careful to note both regional trends and national differences. However, there is no room for complacency - a closer examination suggests that the drug situation may now be in a state of flux, with ‘new’ problems emerging that challenge current policy and practice models In particular our new analysis highlights the ongoing concern about the increasing number of new psychoactive substances appearing on the illicit market in Europe. We will take a look at the latest results in this area at the end of this presentation. For the highlights of our 2013 analysis – results will be presented under 4 main headings: Cannabis, Opioids, Stimulants, and New drugs.

77 milioni adulti hanno usato la cannabis Cannabis use in Europe 77 milioni adulti hanno usato la cannabis 15.4 milioni di giovani hanno usato negli ultimi 12 mesi (6) So let us begin with cannabis - Europe’s most common illicit drug. Cannabis remains the most used illicit drug in Europe and in the world We estimate that just under a quarter or 77 million of European adults (15-64) have tried cannabis at some point in their lives. Around 20 million in the last year. As with other drugs, most of the recent users – 15.4 million - are young adults in the age group 15 to 34 years old. Despite national differences, recent survey data show overall stable or decreasing trends in use.

3 milioni di consumatori giornalieri Giovani maschi over represented (7) Concerns remain around the 3 million Europeans (15–64 years) who still use the drug on a daily basis (around 1 % of the European adult population), highlighting the fact that this drug remains an important public health issue. As this map shows - Daily or almost daily cannabis use (20 days or more in the last 30 days) varies considerably between countries. Young males are overrepresented among frequent and high-risk cannabis users and interventions should be primarily tailored to them. However, older users and females might have different characteristics and needs which should also be addressed. See POD on characteristics of high risk cannabis users While for some young people this frequent use may just be a short term phenomenon, for others, daily use of cannabis over longer periods puts them at risk of developing serious health and social problems and needing treatment.

Cannabis – Cresce la domanda di trattamento La seconda sostanza più frequentemente menzionata nelle ammissioni per trattamento Cannabis Cannabis (8) Cannabis is the second most frequently reported drug, after heroin, among all clients entering specialised drug treatment in Europe. And among those clients entering treatment for the first time in 2011, it was the drug most frequently reported. Our analysis confirms the trend of rising treatment demand for this group. However, considerable national variation can be seen, ranging from 4% of all drug clients reporting this drug as a reason for entering treatment in Bulgaria to 69% in Hungary. These differences can be explained by differences in referral practices, the type of treatment services available and national prevalence levels.

Cannabis treatment: range of approaches Internet-based, brief interventions, family therapy, etc. Più valutazioni di efficacia (9) In Europe, treatment for cannabis users spans a broad range of approaches including Internet-based treatment, brief interventions, multidimensional family therapy, cognitive-behavioural therapy and other structured psychosocial interventions in outpatient or inpatient settings. The availability of cannabis treatment evaluation studies has increased in recent years with, for example, a recent meta-analysis on multidimensional family therapy showing positive results in terms of reducing substance use and retention in treatment. Research is also being conducted on pharmaceuticals that may support psychosocial interventions.

Mercato della cannabis cambia da resina a erba 2001 2011 (10) Two distinct cannabis products are commonly found on the European drugs market: herbal cannabis (‘marijuana’) and cannabis resin (‘hashish’). The annual consumption of these products can be roughly estimated at around 2 500 tonnes. Over the past ten years, the number of herbal seizures has overtaken that of resin, and now represents more than half of all cannabis seizures. This reflects, in part, the growing availability of domestically produced herbal cannabis in many countries. The quantity of cannabis resin seized, however, although falling in recent years, is still much higher than the quantity of herbal cannabis reported (483 tonnes versus 92 tonnes in 2011). Herb Resin

Offerta di cannabis Produzione domestica rilevata in quasi tutti i paesi Violenza associata, Coinvolgimento della criminalità organizzata (11) Domestic cannabis production is now reported by almost all EU countries – sometimes user level and sometimes on a more sophisticated, industrial scale. With it come increasing concerns about the involvement of organised crime gangs, increased associated violence and other crimes.

1.4 million problem opioid users Opioidi Il maggior problema in Europa 1.4 million problem opioid users (13) Use of opioids, mainly heroin, still accounts for the largest share of drug treatment demand and drug-related morbidity and mortality in Europe. Our most recent estimation is that there are about 1.4 million problem opioid users in Europe— (about 0.4% of the adult population 15-64) mainly heroin users but also users of other plant-based or synthetic drugs that are from the same chemical family — this corresponds to about one in every 250 of our adult citizens. Since 2005, countries with repeated prevalence estimates show a relatively stable situation. However, in this years report a number of changes in the heroin market have been identified.

Uso di Eroina – segnali in declino Un minor numero di nuovi clienti che entrano in terapia Invecchiamento della popolazione in trattamento Riduzione assunzione per via parentale Consumatori di Eroina in trattamento (14) Multiple indicators suggest that Europe is currently witnessing a decline in heroin use, although countries show varying patterns and trends. Across Europe, the number of those entering specialist drug treatment for the first time for heroin problems fell from a peak of 59 000 in 2007 to 41 000 in 2011, with reductions most apparent in western European countries. This time difference between the two regions is supported by other analyses which highlight differing time trends in heroin epidemics in these regions. Understanding heroin use trends is a priority due to the public health impact of this drug, and a new analysis of long-term trends in heroin use is released today (see POD) We also see that heroin users in treatment services constitute an aging group. And data from treatment clients also continue to show a decline in injecting the drug. The EMCDDA reports that between 2006 and 2011, there was an overall decrease in the proportion of injectors among heroin clients entering drug treatment for the first time. 10

Decessi per overdose in riduzione Decessi per overdose: Da 7 700 (2009) a 6 500 (2011) (15) Another indicator that heroin use, in particular hewroin injection may be declining, is the recent drop in levels of reports of overdose deaths in Europe as a whole. While over the last decade, Europe has seen more than 70 000 overdose deaths, most among opioid users, recent data shows a more promising trend, - in 2011, 6500 overdose deaths were reported, a drop from 7700 reported last in 2009. However, problem opioid users have an excess mortality, an increased likelihood of dying, which is 10 to 20 times higher than peers in the general population. We estimate of total mortality amongst problem opioid users to be between 10,000 and 20,000 deaths a year.

Declino nelle denunce all’autorità giudiziaria Heroin (16) Across a number of other indicators, there is also evidence of a recent drop in heroin availability. In this graphic we see the decline in the number of heroin-related offences observed in 2009 and 2010 has continued in 2011.

Heroina: segnali di un fenomeno in declino Opioids > La più bassa quantità di sequestri degli ultimi 10 anni (17) Latest seizures figures also point to an overall decrease in heroin supply. The quantity of heroin seized in the EU and Norway in 2011 (6.1 tonnes) was the lowest reported in the last decade and equivalent to about half the quantity seized in 2001 (12 tonnes). Substantial declines in quantities seized are reported by Turkey The number of seizures reported in this period also fell, from 63 000 in 2001 to an estimated 40 500 in 2011. Recent market changes have been linked to severe heroin shortages reported by some countries in late 2010 and early 2011, particularly in Ireland and the UK where law-enforcement successes may have played a role. 13

Stimulanti Nuove Droghe Altri oppiacei etc. Eroina sostituita da… Fentanyl (18) One of the concerns identified by countries experiencing heroin shortages has been the use of replacement substances. These include reports of increased injecting of amphetamines, increased injecting of NPS, particularly cathinones, increased use of benzodiazepines and other medications. Of particular concern have been a worrying spread of fentanyl to the drugs markets outside Estonia. A 2012 EMCDDA ‘trendspotter’ meeting examined the latest developments for fentanyl, which is considerably more potent than heroin and particularly associated with overdose and drug-induced deaths.

Interruzione nella riduzione delle nuove diagnosi per HIV Epidemie HIV in Grecia e Romania del 2011 continuano nel 2012 (19) Continuing with the issue of harms… The injection of drugs continues to be an important mechanism for the transmission of infectious diseases, including HIV/AIDS and hepatitis C. The latest figures show that the long-term decline in the number of new HIV diagnoses in Europe might be interrupted as a result of outbreaks among injecting drug users in Greece and Romania. In 2011, the average rate of newly reported HIV diagnoses attributed to injecting drug use was 3.03 per million population, approximately 1 500 newly reported cases, slightly more than in 2010. This has disrupted the overall downward trend observed since 2004 and underlines the need to provide adequate harm-reduction and treatment services.

Prevenzione dei decessi correlati Take-home naloxone programmes (22) Reducing drug-related deaths remains a major challenge for public health policy in Europe, and another new EMCDDA analysis looks at the variety of factors that increase the risk of fatal and non-fatal overdoses, be they related to patterns of use or setting (e.g. disruption of treatment, release from prison). It also describes how these deaths may be prevented via interventions aiming, on the one hand, to reduce the occurrence of overdose events (e.g. via awareness raising, risk assessment) and, on the other, to prevent fatal outcomes of overdoses (e.g. supervised drug consumption facilities and training to improved bystander response). The latter features training peers and families of drug users to recognise and respond to overdoses, including the administration of an antidote (naloxone) to reverse the effects of opioids. Five countries — Denmark, Germany, Italy, Romania, UK — report pilot projects or programmes providing take-home naloxone to opioid users, their families and carers.

1.2 milioni in trattmento in Europa La terapia sosititutiva è la prima scelta per i consumatori di oppiacei Altre forme di trattamento sono disponibili in tutti i paesi (23) This year, the EMCDDA has once more produced a minimum estimate of the number of people that have been in drug treatment during a given year. It is estimated that at least 1.2 million people receive drug treatment in 2011. This represents a major increase compared with twenty years ago, made possible by the development of outpatient treatment, notably opioid substitution treatment, the involvement of new drug treatment providers such as general practitioners, and the development of new approaches, for example for cannabis or cocaine users. The most common treatment for opioid dependence in Europe is substitution treatment, typically integrated with psychosocial care and provided at specialised outpatient centres or by general practitioners. Psychosocial interventions and detoxification are the other main forms of drug treatment provided. This year we have data on treatment coverage of problem opioid users for 9 countries – see graph. This is based on POU estimates, the number of people receiving substitution treatment and the total number of POUs in treatment. As shown here – all 9 countries have total treatment coverage of over 40%. Low OST coverage can mean it is not the treatment of choice (Hungary) or that overall coverage is low (Cyprus) 17

Substitution treatment – increasing provision 730 000 in terapia sostitutiva Copertura per circa il 50% (24) Some 730 000 Europeans now receive opioid substitution treatment in Europe — up from 650 000 in 2008 — representing around half of the estimated 1.4 million problem opioid users in Europe today. Methadone is the most commonly prescribed medication, received by up to three quarters of clients, while buprenorphine is prescribed to most of the remaining clients, and is the principal substitution medication in five countries. Less than 5% of all substitution treatments in Europe rely on the prescription of other substances, such as slow-release morphine or diacetylmorphine (heroin).

Terapia sostitutiva nelle prigioni Disponibile nella maggior parte dei paesi Ma esistono restrizioni (25) Prisoners with drug problems often have complex health needs but, overall, the provision of drug services in prisons still lags behind provision in the wider community. Opioid substitution treatment now exists in prisons in most countries, but its introduction has been slower than in the community. A recent estimate suggests that at least 74 000 prisoners have received this treatment during the year, although levels of provision vary considerably between countries. Restrictions may also exist, for example, some countries only provide substitution treatment to prisoners who were already receiving it prior to incarceration. See map. There is also a need to ensure continuity of care for prisoners on their release, when the risk of overdose death is elevated due to reduced opioid tolerance. Recent studies report that between 5% and 31% of prisoners have ever injected drugs (Chapter 3). While some prisoners stop or reduce their drug use when incarcerated, others may initiate drug use or engage in more harmful practices (e.g. sharing injecting equipment).

Stimulanti 2,5 milioni di giovani europei usato cocaina nell'ultimo anno 1,8 milioni ha usato ecstasy 1,7 milioni ha usato anfetamine (26) Let’s now move to our recent analyses for the stimulant drugs – the primary focus here will be on the EU situation for cocaine, ecstasy and amphetamines. Cocaine remains the second most used drug in Europe after cannabis: This drug has been used by about 2.5 million have used young Europeans (aged between 15 and 34 years) in the last year. Ecstasy and amphetamine are the most common synthetic stimulant drugs in Europe. The latest estimate is that there were 1.8 million young Europeans aged 15-34 years old who used ecstasy during the past year and similarly 1.7 million who used amphetamines during that period. As with cocaine, both amphetamines and ecstasy use is usually much more widespread among young people who attend clubs or music festivals, and who go out frequently.

Stimolanti: Mercato sempre più complesso Stimulants > Sostanza stimolante predominante Dati sulla prevalenza nell'ultimo anno tra i 15-34 anni (27) This graph illustrates Europe’s complex and geographically divided stimulant market It shows data for young adults from general population surveys and shows that with regard to stimulant of choice, Europe is divided between cocaine, amphetamines and ecstasy. It is interesting to note the geographical spread, with cocaine most popular in a set of countries in the south and west of Europe, amphetamines more popular in the north and ecstasy popular in a set of primarily eastern countries. Understanding overall trends in the use of stimulant drugs is complicated by the fact that they are often substituted for each other, as consumers make choices influenced by availability, price and perceived quality. 21

Riduzione uso di Cocaine (paesi alta prevalenza) Stimulants > Recenti indagini Domande di trattamento Emergenze ospedaliere Decessi (29) Over the last decade, cocaine has established itself as the most commonly used illicit stimulant drug in Europe, although most users are found in a small number of western EU countries. Around 14.5 million Europeans (15–64 years) have tried cocaine in their lifetime; around 3.5 million reporting to have used it in the last year. But today’s report shows that, overall, cocaine use and supply are now both trending downwards. While some countries still report rises in estimated cocaine consumption, recent surveys show signs of falling use among young adults (15–34 years) in the five highest-prevalence countries (Denmark, Ireland, Spain, Italy and UK). And fewer drug users are seeking treatment for cocaine problems. The number of clients reported to be entering specialised treatment for primary cocaine use for the first time fell from 37 000 in 2009 to 31 000 in 2011. Yet acute and chronic problems related to cocaine use continue to be reported. Emergency health consequences of cocaine use come under the spotlight in a new EMCDDA analysis today (see POD), which explores the potential of using hospital emergency data to monitor acute problems linked to the drug. At least 475 deaths related to cocaine were recorded in 2011, although this may be an underestimate.

Cocaina: cambia il traffico? Diversificazione delle rotte del traffico (30) On the supply side, the number of cocaine seizures has fallen from a peak of 100 000 in 2008 to 86 000 in 2011, probably mirroring to some extent decreases in use. In addition, decreases are reported in the quantity of cocaine seized. In 2011, 62 tonnes of the drug were intercepted, an almost 50% drop from the 120 tonnes of cocaine seized in the peak year 2006. The drop in the volume seized has been particularly noticeable in the Iberian Peninsula. This has been linked with recent signs of diversification of cocaine trafficking routes into Europe — including large individual seizures in ports in Bulgaria, Greece, Romania and the Baltic countries — and raises concerns over further diffusion of use.

Crescita del mercato delle metamfetamine ? Amphetamine Methamphetamine (31) Of the two amphetamines, amphetamine has been more common in Europe and recent data show use of amphetamine to be stable or declining among young adults. However there are now signs of rising availability and use of methamphetamine. Methamphetamine seizures, although still small both in number and quantity, rose between 2002 and 2011. And methamphetamine use, historically low in Europe and mainly limited to the Czech Republic and Slovakia, now appears to be spreading, with indications of problem use noted in Germany, Greece, Cyprus and Turkey, but at low levels. Recent EMCDDA Annual reports have pointed to rising availability of methamphetamine and its edging into new territory in the north of Europe, where it has partially been replacing amphetamine as the stimulant drug of choice (Latvia, Sweden, Norway, Finland). Further concerns relate to reports of both methamphetamine smoking in Europe and to reports of methamphetamine-related overdose deaths. Methamphetamine smoking, to date extremely rare in Europe, is known to be particularly damaging to health. In autumn 2013, in response to recent developments, the EMCDDA will launch a ‘trendspotter’ review of this drug which has caused considerable problems outside Europe (e.g. Australia, Japan, New Zealand, USA).

Produzione di droghe sintetiche: precursori e pre-precursori Al controllare una sostanza chimica, i produttori passano semplicemente ad un'alternativa (32) Europe has a long history of producing and consuming synthetic drugs. The region remains important today for the production of amphetamine (usually the sulphate salt), ecstasy-type drugs, especially MDMA, and methamphetamine (usually the hydrochloride salt). The availability of precursors and other chemicals is essential for the manufacturing of synthetic drugs, and while obtaining the appropriate precursor chemicals is an on-going problem for illicit drug producers, ensuring that precursor chemicals are not used for drug production is a major concern for drug supply reduction efforts. Illicit manufacturers, however, have adapted to shortages in chemicals by importing non-scheduled chemicals sometimes referred to as ‘pre-precursors’ and ‘masked’ (or ‘designer’) precursors. This situation presents a challenge to controlling policies, as a greater number of chemicals need to be considered, some of which have legitimate uses. There is always a risk that as one chemical comes under scrutiny, producers will simply switch to an alternative ‘pre-precursor’ chemical that can be used for illicit drug production - hence the cat and mouse analogy (see graphic). The recent analysis (POD) states that the most serious challenge now facing law enforcement in manufacturing countries is the chemical alpha-phenylacetoacetonitrile (APAAN), a precursor of BMK (the precursor of both amphetamine and methamphetamine). APAAN is placed on the European Commission’s voluntary monitoring list, but the chemical is not placed under international control.

Ecstasy: il ritorno? MDMA in ripresa (33) Another aspect of the synthetic stimulants market which is showing signs of change is that of ecstasy. The seizure of ecstasy tablets containing MDMA has been on the wane in Europe for a number of years, but has recently rebounded with high content MDMA tablets and powders now being found in a number of countries.

Nuove droghe Circa 280 nuove droghe monitorate dall OEDT (34) Let us finish with a look at developments regarding new psychoactive substances One of our main tools to follow drug market innovation is the EU early-warning system. Currently around 280 substances are monitored by the EWS, and according to our latest data, new drugs continue to be reported in the EU at the rate of more than one per week. Circa 280 nuove droghe monitorate dall OEDT

cannabinoidi sintetici in 2012 73 nuove sostanze nel 2012 30 cannabinoidi sintetici in 2012 (35) In 2012, 73 new psychoactive substances were officially notified for the first time via the EU Early warning system (EWS) Of these substances, 30 were synthetic cannabinoids, which mimic the effects of cannabis. These can often appear on the ‘legal highs’ market - in internet or physical shops - as herbal smoking blends, incense or Spice-like products. These products, which can be extremely potent, have now been reported in virtually all European countries. A new EMCDDA analysis out today (see ‘POD’), provides an update on the current knowledge on synthetic cannabinoids, which now represent the largest group of compounds monitored by the EWS. Of the other compounds detected in 2012, 19 substances were from ‘less known or more obscure chemical groups’, including medicines. Also of note were the 14 new substituted phenethylamines (the chemical group that includes amphetamine and 'ecstasy'), the highest number reported since 2005.

Emergence cannabinoidi sintetici in Europa Polveri prodotte in e importate dalla Cina Mescolate, e/o spruzzate su, erbe Confezionato per la vendita come 'sballo legale' (36) Synthetic cannabinoid products, which can be extremely potent, have now been reported in virtually all European countries. The number of substances, their chemical diversity and the rate of their emergence makes this group of compounds particularly challenging in terms of detection and monitoring. This POD provides an update on the current knowledge on these substances and their effects, as well as trends in production, availability and use. Multi-kilogram quantities in powder form are usually imported from Asia, with processing and packaging then occurring in Europe. The powder is then mixed with or sprayed onto herbs – sometimes in major quantities – see graphic. The dried, and packaged for sale as ‘legal highs’ Although synthetic cannabinoids were probably available on the market as herbal blends from 2006 or before, it was only in 2008 that forensic investigators detected the substance JWH-018 in ‘Spice’ products. Since 2008, synthetic cannabinoids have continued to be reported via the EWS at a rapid rate: 9 in 2009, 11 in 2010, 23 in 2011 and 30 in 2012. Relatively little is known about the pharmacology and toxicology of synthetic cannabinoids, but there have been reports in Europe of non-fatal intoxications and a small number of fatal cases associated with the use of products containing them. New trends in the area of synthetic cannabinoids includes: the emergence of resinous products containing these substances; their detection in tablets resembling ‘ecstasy’ the presence of these chemicals in samples of herbal cannabis; and their detection in mixtures containing other, unrelated chemicals (e.g. tryptamines, synthetic cathinones).

La scommessa de controllo Controllo sulle nuove droghe in Europa (39) Across Europe, a variety of measures are being developed to reduce the demand for, and supply of, new drugs. The speed at which new psychoactive substances can appear challenges countries’ established legislative procedures for drug control. Several countries have responded with innovative changes to their legislation or enforcement policies geared towards controlling the open sale of these substances. Our new analysis (see POD) looks at three types of legal response to this phenomenon, including: controls using consumer safety or medicines legislation; extending and adapting existing laws and processes; and devising new legislation to tackle new substances.

In summary Il consumo di droga rimane alto ma alcuni cambiamenti positivi apparenti: Livelli record di trattamento, riduzione del mercato dell’eroina e per via parentale Tendenza stabile o al ribasso per altre ‘vecchie droghe’ MA… ‘Nuovi' problemi emergono all’emergere delle nuove droghe Preoccupazione che la disoccupazione e i tagli ai servizi possano far riemergere "vecchi" problemi (40) To finish, let me briefly summarise some of the main points of our 2013 European Drug Report…. Although drug use remains high by historical standards, a number of positive changes are apparent: This includes record levels of treatment provision, declines in new heroin use and a long term erosion in injecting In addition we note either stable or declining trends for most other ‘old’ drugs (cocaine, amphetamine, cannabis) BUT We remain concerned about potential ‘New’ problems emerging that are linked to ‘new’ psychoactive substances – reports of increased cathinone injection among problem drug users in some countries, for example. And finally, we need to remain vigilant with regard to the risk that in some European countries the increasing levels of youth unemployment and service cuts could lead to a re-emergence of ‘old’ problems

European drug report package A comprehensive analysis on the drugs problem in Europe (2) Central to the brand new EDR package is this report on Trends and developments (also available online), which provides a top-level summary of trends and developments. Additional layers to the package are provided by the Statistical bulletin, Country overviews and Perspectives on drugs (PODs).

PODs – Prospettive sulle Droghe Campagne mediatiche Trattamento dell'epatite C Prevenire decessi per overdose Conseguenze per la salute nel consumo di cocaina Tendenze nel trattamento di eroina Caratteristiche dei consumatori di cannabis ad alto rischio Nuova strategia antidroga della UE Il controllo delle nuove sostanze psicoattive Modelli per l'offerta legale di cannabis Cannabinoidi sintetici Produzione di droghe sintetiche (4) As part of the 2013 we are launching 11 new Perspectives on drugs (PODs) which provide deeper insights into important issues, which this year include new treatment approaches for hepatitis C, high-risk cannabis use and the control of increasingly available new psychoactive substances etc.