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2015 - Gouvernement
/ National Report on the State of the Drugs Phenomenon 1A-1B, rue Thomas Edison L-1445 STRASSEN LUXEMBOURG Tel : (352) 26 97 07 - 39 / 49 Fax : (352) 26 97 07 19 Grand Duchy of Luxembourg New developments,trends and in-depth information on selected issues L’état du phénomène des drogues et des toxicomanies au Grand-Duché de Luxembourg LIH / Point focal OEDT LUXEMBOURG 2015 Point Focal Luxembourgeois de l’Observatoire Européen des Drogues et des Toxicomanies 2015 National Drug Report Point Focal Luxembourgeois de l’Observatoire Européen des Drogues et des Toxicomanies national drug report edition 2015 2015 L’ETAT DU PHENOMENE DES DROGUES ET DES TOXICOMANIES AU GRAND-DUCHE DE LUXEMBOURG THE STATE OF THE DRUGS PROBLEM IN THE GRAND DUCHY OF LUXEMBOURG EDITION 2015 Luxembourg Institute of Health POINT FOCAL LUXEMBOURGEOIS de l’O.E.D.T. Dr Alain ORIGER Sofia LOPES DA COSTA Céline DIEDERICH Simone SCHRAM Ana BERZIRGANI 1A-B,rueThomasEdison L-1445STRASSEN LUXEMBOURG Tél.:+352269707-39/49 Fax:+35226970719 RESEAUNATIONALD’INFORMATIONSURLESDROGUESETLESTOXICOMANIES(R.E.L.I.S) 1 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 CONTENTS RESUME.........................................................................................................................................................................7 Orientations politiques et budgétaires ................................................................................................................. 7 Indicateurs épidémiologiques.................................................................................................................................. 8 Offres de traitement des toxicomanies ............................................................................................................... 11 Morbidité et mortalité liées à la consommation illicite de drogues............................................................ 11 Conséquences sociales et mesures de réintégration ....................................................................................... 12 Mesures de réduction des risques ......................................................................................................................... 12 Indicateurs de réduction de l’offre ....................................................................................................................... 13 Disponibilité et qualité des drogues illicites au niveau national................................................................. 14 Tendances essentielles............................................................................................................................................. 14 Concordance entre indicateurs.............................................................................................................................. 16 SUMMARY..................................................................................................................................................................17 Drug policy: legislation, strategies and economic analysis ...........................................................................17 Epidemiological Indicators .....................................................................................................................................17 Drug-related treatment .......................................................................................................................................... 20 Health correlates and responses to consequences ......................................................................................... 20 Social correlates and social reintegration ......................................................................................................... 21 Harm reduction activities ...................................................................................................................................... 21 Law enforcement indicators .................................................................................................................................. 21 Profile of the national drug market ..................................................................................................................... 22 Most relevant trends ............................................................................................................................................... 23 Consistency between Indicators .......................................................................................................................... 24 PART A: NEW DEVELOPMENTS AND TRENDS ................................................................................... 25 1. Drug policy: legislation, strategies and economic analysis ....................................................... 25 •GENERALLEGALFRAMEWORK................................................................................................................................... 25 •NATIONALACTIONPLAN,STRATEGY,EVALUATIONANDCOORDINATION.............................................. 28 •ECONOMICANALYSIS..................................................................................................................................................... 33 2. Drug use in the general population and specific targeted groups .......................................... 38 •DRUGUSEINTHEGENERALPOPULATION............................................................................................................ 38 •DRUGUSEINTHESCHOOLANDYOUTHPOPULATION..................................................................................... 41 •DRUGUSEAMONGTARGETEDGROUPS................................................................................................................. 52 3. Prevention ............................................................................................................................................... 56 •ENVIRONMENTALPREVENTION.................................................................................................................................. 57 •UNIVERSALPREVENTION............................................................................................................................................... 61 •SELECTIVEPREVENTIONINAT-RISKGROUPSANDSETTINGS......................................................................... 70 •INDICATEDPREVENTION.............................................................................................................................................. 78 •NATIONALANDLOCALMEDIACAMPAIGNS......................................................................................................... 79 2 5. Drug-related treatment: treatment demand and treatment availability ............................... 89 •DRUGTREATMENTSTRATEGIESANDPOLICY....................................................................................................... 89 •TREATMENTSYSTEMS..................................................................................................................................................... 90 •CHARACTERISTICSOFTREATEDCLIENTSANDTRENDSOFCLIENTSINTREATMENT........................... 96 6. Health correlates and consequences ............................................................................................. 101 •DRUG-RELATEDINFECTIOUSDISEASES................................................................................................................. 102 •OTHERDRUG-RELATEDHEALTHCORRELATESANDCONSEQUENCES..................................................... 105 •DRUG-RELATEDDEATHSANDMORTALITYOFDRUGUSERS....................................................................... 107 2015 4. Problem Drug Use................................................................................................................................. 81 •PREVALENCEANDINCIDENCEESTIMATESOFPDU........................................................................................... 82 •DATAONPDUFROMNON-TREATMENTSOURCES.............................................................................................. 88 7. Responses to health correlates and consequences .....................................................................113 •PREVENTIONOFDRUG-RELATEDEMERGENCIESANDREDUCTIONOFDRUG-RELATEDDEATHS.....113 •PREVENTIONANDTREATMENTOFDRUG-RELATEDINFECTIOUSDISEASES...........................................117 •RESPONSESTOOTHERHEALTHCORRELATESAMONGDRUGUSERS....................................................... 120 8. Social correlates and social reintegration .................................................................................... 122 •SOCIALEXCLUSIONANDDRUGUSE...................................................................................................................... 122 •SOCIALREINTEGRATION............................................................................................................................................. 126 9. Drug-related crime, prevention of drug-related crime and prison ......................................... 128 •DRUG-RELATEDCRIME................................................................................................................................................ 128 •PREVENTIONOFDRUG-RELATEDCRIME.............................................................................................................. 132 •INTERVENTIONSINTHECRIMINALJUSTICESYSTEM...................................................................................... 133 •DRUGUSEANDPROBLEMDRUGUSEINPRISONS.......................................................................................... 133 •RESPONSESTODRUG-RELATEDHEALTHISSUESINPRISONS...................................................................... 134 •PREVENTION,TREATMENTANDCAREOFINFECTIOUSDISEASES.............................................................. 136 •REINTEGRATIONOFDRUGUSERSAFTERRELEASEFROMPRISON............................................................. 138 10. Drug Markets .....................................................................................................................................139 •AVAILABILITYANDSUPPLY........................................................................................................................................ 139 •SEIZURES............................................................................................................................................................................ 143 •PRICE/PURITY................................................................................................................................................................. 146 PART B ........................................................................................................................................................ 149 Bibliography.............................................................................................................................................. 149 ANNEX I ..................................................................................................................................................... 158 ANNEX II .................................................................................................................................................... 161 3 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition ABBREVIATIONS 4 AST Serviced’ActionSocio-Thérapeutique CATF ChemicalActionTaskForce CePT CentredePréventiondesToxicomanies CAS Commissiond’admissionetdesurveillance(CHDP) CFSP CommonForeignandSecurityPolicy CHNP CentreHospitalierNeuro-Psychiatrique CICAD Inter-AmericanDrugAbuseControlCommission CMO ComprehensiveMultidisciplinaryOutline(UN) CND CommissiononNarcoticDrugs CNDS ComitéNationaldeDéfenseSociale CNER ComitéNationald’EthiquedeRecherche CNPD CommissionNationaledeProtectiondesDonnées CPG CentrePénitentiairedeGivenich CPL CentrePénitentiairedeLuxembourg CPOS CentredePsychologieetd’OrientationScolaire CRP-HT CentredeRecherchePublic-HenriTudor CRP-Santé CentredeRecherchePublic–Santé CTM CentreThérapeutiquedeManternach DEA DrugEnforcementAdministration(UnitedStates) EWS EarlyWarningSystemonNewSyntheticDrugs GID GroupeInterservicesDrogue(delaCommissioneuropéenne) EMCDDA/OEDT EuropeanMonitoringCentreforDrugsandDrugAddiction EMEA EuropeanMedicinesAgency EUROPOL EuropeanPoliceOffice FBI FederalBureauofInvestigation(UnitedStates) FED FondEuropéendeDéveloppement FATF FinancialActionTaskForceonMoneyLaundering FEDER FondEuropéendeDéveloppementRégional FLTS FondsdeLuttecontreleTraficdesStupéfiants HAT HeroinAssistedTreatment HDG HorizontalWorkingPartyonDrugs 15 HeadsofNationalDrugLawEnforcementAgencies ICD InterministerialCommissiononDrugs ICPO/Interpol InternationalCriminalPoliceOrganization ILO InternationalLabourOrganization INCB InternationalNarcoticControlBoard JDH FondationJugend-anDrogenhëllef LIH LuxembourgInstituteofHealth LNS LaboratoireNationaldeSanté NDLEA NationalDrugLawEnforcementAdministration(Nigeria) NFP NationalFocalPointoftheEMCDDA NIDA NationalInstituteonDrugAbuse(UnitedStates) OAS OrganizationofAmericanStates OCDE OrganisationdeCoopérationetdeDéveloppementEconomiques OGD ObservatoireGéopolitiquedesDrogues OLAF EuropeanAnti-FraudOffice ONDCP OfficeofNationalDrugControlPolicyoftheWhiteHouse(UnitedStates) PECO Paysd’EuropeCentraleetOrientale RELIS RéseauLuxembourgeoisd’InformationsurlesStupéfiants REITOX EuropeanInformationNetworkonDrugsandDrugAddiction SADC SouthernAfricanDevelopmentCommunity SCRIPT ServicedeCoordinationdelaRechercheetdel’Innovationpédagogiqueset technologiques SEPT SemaineEuropéennedePréventiondesToxicomanies SID Systèmed’InformationDouanier SIS Systèmed’InformationSchengen SNJ ServiceNationaldelaJeunesse SPG SystèmedePréférencesGénéralisées SPJ ServicedesStupéfiantsdelaPoliceJudiciaire TRANSRELIS Réseautransfrontalierd’InformationsurlesStupéfiants UNDCP UnitedNationsInternationalDrugControlProgramme UNDP UnitedNationsDevelopmentProgramme UNGASS UnitedNationsGeneralAssemblySpecialSessiononDrugs UNODC UnitedNationsOfficeonDrugsandCrime WCO WorldCustomsOrganization WHO WorldHealthOrganization ZePF ZentrumfürEmpirischePädagogischeForschung–UniversitätLandau 2015 Honlea 5 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 AVANT-PROPOS Lerapport2015surl’étatduphénomènedesdroguesetdestoxicomaniesauGrand-DuchédeLuxembourg (RELIS) vise à situer le contexte dans lequel s’inscrivent l’usage et le trafic illicites de drogues et les toxicomanies au niveau national en proposant une vue d’ensemble des évolutions historiques et des tendancesactuellementobservéesenlamatière. Les experts et institutions suivants ont été consultés: Dr Arno Bache (Direction de la Santé), Catherine Trierweiler(MinistèredelaJustice),Jean-PaulSchirtzetMichelleWolff(AdministrationdesDouanes),Claude Frieden(CNS),SteveSchmitzetSophieHoffman(PoliceGrand-Ducale),GuyTheisen,GuyReinartetSimone Schram(DirectiondelaSanté),RobertWelter(Parquet),DrSergeSchneideretDrMichelYegles(Laboratoire NationaldeSanté)ainsiquel’ensembledesONGnationalesspécialiséesenmatièredepriseencharge. FOREWORD The2015editionofthenationalreportonthestateofthedrugsproblemintheGrandDuchyofLuxembourg aims to describe the framework in which drug use and drug trafficking evolve at the national level by providingacomprehensiveoverviewofhistoricaldevelopmentsandrecenttrends. Thanksareduetothefollowingexpertsandinstitutionsconsultedintheframeworkofthe2015edition ofthereport:DrArnoBache(DirectorateofHealth),CatherineTrierweiler(MinistryofJustice),Jean-Paul SchirtzandMichelleWolff(CustomsAdministration),ClaudeFrieden(CNS),GuyTheisen,GuyReinartand Simone Schram (Ministry of Health), Steve Schmitz and Sophie Hoffmann (Police), Robert Welter (Public Prosecutor’sOffice),DrSergeSchneiderandDrMichelYegles(NationalLaboratoryofHealthLNS)aswellas allnationalspecialisedNGOs. 6 RAPPORTNATIONALSURL’ETATDUPHÉNOMÈNEDESDROGUESETDESTOXICOMANIES AUGRAND-DUCHÉDELUXEMBOURG (RELIS - Edition 2015) Depuissacréationen1994,lePointFocalLuxembourgeois(PFN)del’ObservatoireEuropéendesDrogues etdesToxicomanies(OEDT)maintientetdéveloppeledispositifdesurveillanceépidémiologiqueenmatière dedroguesetdetoxicomanies,connusouslenomdeRéseauLuxembourgeoisd’InformationsurlesDrogues etlesToxicomanies(RELIS). 2015 RESUME RELISreposesurunearchitectured’informationmultisectorielincluantlescentresnationauxambulatoires etrésidentielsdetraitementspécialisé,lescentresdeconsultation,certainshôpitauxgénéraux,ainsiqueles instancesjudiciairesetpénalescompétentes. Les efforts déployés depuis plus de 20 années ont permis de constituer une base de données nationale annuellementmiseàjour,permettantnotamment: - desituerlaprévalence,l’incidenceetl’évolutiondel’usageproblématiquededroguesillicitesauniveau national; - deservirdesupportscientifiqueetdebasededonnéespourl’activitéderecherche; - d’évaluer les tendances nouvelles et l’impact de certaines interventions sur les comportements et caractéristiquesdelapopulationd’usagersproblématiquesdedrogues(UPD)etdefaciliterl’analyse desbesoinsetleprocessusdécisionnelauniveaupolitiquelorsdelamiseenplacedeplansd’actionet destratégiesd’interventionenmatièredeluttecontrelesaddictions. ORIENTATIONS POLITIQUES ET BUDGÉTAIRES Legouvernementaconfiélacoordinationdesactionsderéductiondelademandeetdesrisquesassociésàla drogueetauxtoxicomaniesauMinistèredelaSanté,cequiadonnélieuàladésignationd’unCoordinateur National«Drogues»en2000. Leprogrammegouvernementalde2009aservidecadreàl’élaborationdelatroisièmestratégienationale et du plan d’action pluriannuel en matière de lutte contre les drogues et les addictions. La stratégie et le plan d’action 2010-2014s’appuiaientsurlesprioritésfixéesparleMinistèredelaSantéetsur unecollaborationsoutenueaveclesacteursdeterrain.Afind’optimisersonimpact,lepland’action20102014aégalementtenucomptedesélémentspertinentsissusdestraitésUEetCE, de la stratégie antidrogue 2005–2012 et duplan d’action drogues 2009–2012 de l’UE. Le nouveau plan d’action gouvernemental 2015-2019 a par ailleurs été élaboré sur base d’une évaluation externe du plan d’action 2010-2014. L’objectif général de la stratégie et du plan d’action nationaux est de contribuer à atteindreunniveauélevédeprotectionentermesdeSantépublique,deSécuritépubliqueetdecohésion sociale. Unestratégieanti-droguequiveutfairefaceauxdéfisactuelsreposeprioritairementsurdeux piliers,à savoirlaréductiondelademandeetlaréductiondel’offreainsiquesurquatre axes transversaux:1.la réductiondesrisques,dommagesetnuisances,2.larechercheetl’information,3.lesrelationsinternationales et4.lesmécanismesdecoordination.Lecoordinateurnational«drogues»,encollaborationavecleGroupe Interministériel«Toxicomanies»(GIT),suitetajustelesprocessusdemiseenœuvredupland’actionen matièredeluttecontrelesdroguesetlesaddictions. 7 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Le budget global du Ministère de la Santéallouéauxservicesetprogrammesdudomainedesdrogues etdestoxicomanies,estpasséde2.066.000.-EURen2000à10.949.211.-EURen2014cequiéquivautà untauxdeprogressionde 430%.En2000,lenombredepostesETPconventionnésparleMinistèredela Santéetallouésauxstructuresspécialiséesissuesdudomainedestoxicomaniess’élevaità30,75;ilaatteint 110,75ETPen2014.Defaçongénérale,lesdépensespubliquesenmatièredeluttecontrelesdrogueset les toxicomanies sont estimées à 38,5 millions EUR (Origer, 2010). Les dépenses allouées exclusivement auxtraitementsdesproblèmesliésàl’usagededroguesillicitesreprésentaient16,2millionsEURen2012. INDICATEURS ÉPIDÉMIOLOGIQUES Al’échellemondiale(UNODC,2015)1,lenombreglobaldepersonnesâgéesde15à64ansayantconsommé au moins une drogue d’origine illicite au cours de l’année écoulée est estimé entre 246 millions, ce qui équivaut à 1 personne sur 20 au niveau de la population mondiale dans cette classe d’âge. L’usage à caractère problématique de drogues illicites concerne quelque 27 millions de personnes, dont la moitié sontdesinjecteurs.L’UNODCestimeque1,65millionsd’usagersparinjectionsontVIH+.Lecannabisreste deloinladroguelaplusconsommée2aumonde(177,63millionsdepersonneséquivalantà3,8%dela population mondiale telle que définie). L’usage des stimulants de type amphétamine (STA) s’élèverait à 34,40millionsdepersonnes(0,7%).Laprévalencede«l’ecstasy»(18,75millionsdepersonnesou0,4%dela population)adiminuéparrapportauxdonnéesde2009.Lenombredeconsommaterusd’opiacésestresté stableetsesitueraitapproximativementà16,5millionsdepersonnes(0,435%). Auseindel’UEselonlesdernièresdonnéesdel’OEDTissuesduRapporteuropéensurlesdrogues2015,80 millionsdepersonnesontconsomméunedrogueilliciteaucoursdeleurvie.L’usagededroguesenEurope restehistoriquementélevé.Lesévolutionspositivesconcernenttoutefoisunebaissedesnouveauxusagers d’héroïne, une diminution du recours à l’injection, le recul des décès liés à la drogue et une utilisation moindreetenrégressiondel’usagedecannabisetdecocaïnedanscertainspays.Aussi,desniveauxrecords dunombredepersonnesentraitementontétéobservés(1,2millionsd’Européensen2011)etonaconstaté quel’infectionparleVIHliéeàlaconsommationdedroguescontinueàdécroître.Lesamphétamineset l’ecstasydemeurentlesstimulantsdesynthèselesplusfréquemmentconsommésenEurope.Desdonnées récentessuggèrenttoutefoisquel’usaged’amphétamineseststableouenbaissechezlesjeunesadultes. Encequiconcernelecannabis,environ1%d’Européensadultes(de15à64ans)consommentladrogue quotidiennementoupresquequotidiennement.11,7%desjeunesEuropéens,âgésentre15-34annéesont consomméducannabisaucoursdel’annéeécoulée.Aussi,lenombre,letypeetladisponibilitédenouveaux produitspsychoactifsenEuropeontcontinuéàcroître.Lamondialisation,lesavancéestechnologiqueset l’internetontcontribuéaudéveloppementd’unmarchéouvertàcesmêmesproduits. Al’échellemicro-géographique, lestendancesauGrand-DuchédeLuxembourgreflètentdanslesgrandes lignescellesobservéesauseindel’UE, avectoutefoisdesvariationslocalesenmatièredeprévalenceplus oumoinsprononcéesetunetendanceàlabaissedutauxdeprévalencegénéraledel’usageproblématique dedroguesd’origineillicite. 1 2 8 UNODC(2015),Rapportmondialsurlesdrogues2014,UNODC,Vienne. Laprévalenceetletauxdeprévalenceparproduitserapportentàlaconsommationaucoursdel’annéeécouléedepersonnesâgées de15à64ans. Prévalence en population générale au G.-D. de Luxembourg Desdonnéescomparablesissuesd’enquêtesscolairesmenéesentre1999et2010témoignaientd’untaux de prévalence « vie » (consommation au moins une fois au cours de la vie) généralement décroissante encequiconcernelaconsommationdedroguesillicites,toutescatégoriesconfondues.Uneanalyseplus approfondierévèleunebaissetangibledelaprévalence-viedel’usagededroguesillicitesentre1999et 2006suivid’unestabilisationsubséquente.Toustypesdedroguesillicitesontsuivicettemêmetendanceà l’exceptiondelacocaïnequiaconnuunepopularitécroissantesurtoutenmatièred’expérimentationparmi lesjeunesâgésentre15et16ans.L’usaged’opiacésparlesjeunes(16à20ans)continuetoutefoisde témoignerd’uneprévalencebasse. 2015 Prévalence d’usagers de drogues au sein de la population scolaire Bienquelecannabisdemeureladrogueillicitelaplusconsomméeparmilesjeunesde12à18ans,une baisseauniveaudel’usage-vieàpartirdudébutdu21ièmesiècleapuêtreobservéeauniveaunational. Lestauxdeprévalencedel’usagerécentouactueldecannabisparmicesmêmesjeunesontaffichéune tendanceàlabaissemanifesteentre1999et2006poursestabiliserensuite. L’âgemoyenlorsdelapremièreconsommationdecannabisetdedroguesillicitesengénéralparlesjeunes âgés de 12 à 18 ans a augmenté de plus au moins 6 mois depuis 2006. En 2010, 9,44% des jeunes questionnésontrapportéunepremièreconsommationdecannabisavantl’âgede15ansalorsquecemême tauxétaitde12,03%en2006. Une étude en cours (European Health Interview Survey - EHIS) fournira de nouvelles données sur la prévalencedel’usagededroguesenpopulationgénéraleen2016. Prévalence de l’usage problématique de drogues (UPD)3 Contacts institutionnels et recours aux institutions sanitaires pour des problèmes liés aux drogues illicites Le nombre d’UPD indexés par les institutions nationalesen2014équivalaità5.8064personnes (2002:4.701). A titre comparatif, on retiendra qu’en 2002, 2.383 personnes furent recensées par les institutions de réduction de la demandeet2.318parlesinstances de réduction de l’offre.En2014,cesmêmes instancesontrecensérespectivement2.791et3.015personnes.Sommairement,lenombredepersonnes entréesencontactavecdesinstancessanitairesetrépressivesabaisséentre2011et2013pourafficher unehausseen2014.En2014uneaugmentationdunombredecontactsnotammentparlesinstancesde réductiondel’offreestànoter.Ladiminutionantérieuredoitcependantêtreavanttoutattribuéeàune diminutiondunombredecontactsaveclesforcesdel’ordrequicontrasteavecuneaugmentationdunombre d’usagersentraitement.Parailleurs,lenombredepatientsentraitementaiguenmilieuhospitaliereten traitementdesubstitutions’eststabiliséaucoursdesdernièresannéesalorsquelestraitementsspécialisés extrahospitaliersontgagnéduterrain.Anoterenfinlahausseauniveaudunombredecontactsenregistrés parlesservicesdebasseuiletderéductiondesrisquesentre2013et2014. 3 4 Leterme’UPD’serautilisépourdésignerdes‘Usagersproblématiquesdedroguesd’acquisitionillicite’toutaulongduprésentrapport. Danscerecensementlescomptagesmultiplessontincluscequisignifiequ’unepersonnedonnéeapuêtreindexéedeuxfoisouplus siontientcomptedel’ensembledesinstitutionsspécialiséesétabliessurleterritoirenational.Dèslors,cechiffrenereprésentepasla prévalence(lataille)effectivedelapopulationd’UPDauniveaunational(quielle,sedéterminepardesméthodologiesdifférentes). 9 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Caractéristiques socio-démographiques de la population nationale d’UPD Le sex-ratio(M/F)delapopulationdesUPDestactuellementde4:1.Surlesdixdernièresannées,on constatequelaproportionderessortissantsétrangers parmilesUPDrecensésatémoignéd’importantes fluctuations affichant cependant une tendance à la hausse à partir de 2003, qui s’est stabilisée entre 2008(52%)et2014.Lapopulationdesnon-luxembourgeois(es)estprincipalementcomposéedecitoyens d’origineportugaisedontlaproportion(32%del’ensembledesUPDnon-luxembourgeois)estactuellement comparable à celle observée au sein de la population générale (36,5%). Les UPD d’origine africaine et françaiseoccupentrespectivementledeuxième(24%)ettroisième(11%)rang.Lescitoyensbelgesoccupent le4ièmerangensembleaveclescitoyensallemands(5%). L’âge moyendesusagersrecensésestpasséde28anset4moisen1995à32anset3moisen2014.L’âge moyendesUPDmasculinsaaugmentéplusrapidementqueceluidesfemmes.L’écartentrelesusagersles plusjeunesetlesplusâgéss’eststabilisérécemment.L’augmentationdanslaclassed’âgede40années etplusdesUPDetunediminutiondesUPDâgésdemoinsde30années,tendanceobservéeaucoursdes dernières années, ne s’observe plus. L’âge moyen des UPD luxembourgeois est inférieur à celui des UPD non-luxembourgeois. On retiendra également l’accroissement significatif de l’âge moyen des victimes de surdoses mortelles aucoursdeladernièredécennieetunecroissancedemineursparmilesprévenus pourinfraction(s)STUPdepuislesquatredernièresannées(2014:9%,2013:11%;2012:10%;2011: 6%;2010:9%;2009:6%). Prévalence de l’usage problématique de drogues (UPD) et tendances de consommation LesdonnéesnationalesenmatièredeprévalenceUPDsontissuesd’étudessériellesmenéesen1997,1999, 2000,2007et2009,(Origer,2012)5.Enréférenceauxdonnéeslesplusrécenteslaprévalenceetletaux deprévalenceUPDactuelssontestimésrespectivementà2.070personnes(I.C.(95%):1.553–2.623) et 6,16 par mille personnes issues de la population nationale âgée entre 15 et 64 années. De l’analyse des données sérielles de 1997 à 2009 ressort que la prévalence absolue et les taux de prévalence de l’usageproblématiquededroguesontconnuunehaussemarquéejusqu’en2000,s’engageantensuitesur unplateaudestabilisationpourafficherunetendanceàlabaisseàpartirde2003.Laprévalenceabsolue etletauxdeprévalencedel’usageintraveineux(IDU)auseindelapopulationâgéeentre15et64années ontlégèrementaugmentéentre1997et2007etaffichentlespremierssignesdedécroissanceenréférence auxrésultatsderecherchede2009. L’usage intraveineux d’opiacés et de cocaïne associé à une polyconsommation généralisée constituedeloinlecomportementleplusobservéauseindesUPDrépertoriésparleréseauinstitutionnel. Leratioentreusagersintraveineuxetnon-intraveineuxs’eststabiliséà3:2en2014.Laprévalencedel’usage decocaïneentantquedroguepréférentielleafficheunetendancediscontinueàlabaissedepuis2006.En 2014,lacocaïneentantquedroguepréférentielleenregistreuneaugmentationnotable(19,9%),comme déjàen2013(17,3%). Le nombre de personnes en contact avec le réseau institutionnel spécialisé pour usage (préférentiel) de cannabisreprésenteactuellement25,5%(légèrebaisseparrapportà2013:31,1%).Lessubstancesde type amphétamines et ecstasysontfaiblementreprésentées,cequitoutefoisnerenseignenullementsur laprévalencedeleurusageenpopulationgénéraleétantdonnéquelesdonnéesRELISportentsurl’ensemble desusagersproblématiquesactuelsetnerecensentdèslorspaslatotalitédesusagersrécréationnels.Le tauxdepolytoxicomanie(47%en2013)adiminuéentre2011et2013etaaugmentédenouveauen 2014(54%). 5 10 Origer A. PrevalenceofProblemDrugUseandInjectingDrugUseinLuxembourg:ALongitudinalandMethodologicalPerspective. Eur Addict Res. 2012;18:288-296. Lesstructuresspécialiséesenmatièredetraitementdestoxicomaniessontsoumisesàl’obligationdedisposer d’unagrémentàaccorderparleMinistredelaSantéetsontpourlaplupartconventionnéesparl’Etat.Ces deuxmécanismespermettent,enassociationavecd’autresinstruments,d’unepartlecontrôledequalitéet del’autrelefinancementoulecofinancementdesstructuresvisées. Lenombredepatientsadultesentraitementambulatoiretendàsestabiliser,tandisquelenombredepatients entraitementrésidentielspécialiséetlesdemandeursmineursdetraitementambulatoireaaugmentéde façoncontinue.Depuis2010,lenombrededemandeursdetraitementdesubstitutions’eststabiliséetle nombredecontactsavecl’ensembledesstructuresd’accueilàbas-seuil(2014:131,375;2013:124,048; 2012:127.0802010:140.093contacts)adiminuéentre2010et2013.En2014,lenombredecontacts aveclesstructuresbas-seuils’élevaità131,375contacts.Touscentresetservicesdetraitementconfondus, 12,5%desclientsontformuléleurpremièredemanded’aideen2014.Unetendancequiseconfirmeestune baissedelaproportiondepatientsentraitementdesubstitutionâgésdemoinsde25ansetunehausseau niveaudecelleregroupantlespersonnesâgées40ansetplus. 2015 OFFRES DE TRAITEMENT DES TOXICOMANIES MORBIDITÉ ET MORTALITÉ LIÉES À LA CONSOMMATION ILLICITE DE DROGUES LaprévalencedescasVIH/Sidaauseindelapopulationd’UPDestglobalementstabledepuislesdernières années,bienqu’àl’instard’uncertainnombred’autrespaysdel’UE,laproportiond’usagersdedrogues parmi les cas de nouvelles infections HIV a suivi une tendance à la hausse depuis 2013. L’infection à l’hépatite C témoigned’unestabilisationen2014comparéeauxdonnées2013. La proportionmoyenned’usagersintraveineuxdedroguesparmilespersonnesnouvellementinfectéespar le VIH,sesituaitautourde8%entre2012et2013alorsqu’elleaatteint20%pourlapériode2014-2015. Sicettehausse,quis’observeégalementdanscertainsautrespaysdel’UEpeuts’expliquerenpartiepar unecouverturededépistageaccrueauseindelapopulationd’usagersdedroguesauniveaunational,des facteurstelsquelaconsommationaccruedestimulants,etenparticulierdecocaïneparinjectionpardes usagerspolyconsommateursfortementmarginalisés,semblentêtreenjeu.Letauxd’infectionVIHparmi lesusagersintraveineuxsesitueactuellementautourde5%(stabilisationparrapportauxdonnées2013). Laconcrétisationdesplansd’actionconsécutifsaétéaccompagnéed’unebaissediscontinuemaistangible dutauxde décès par surdosageauGrand-DuchédeLuxembourg(8casen2014).Expriméeennombre decasdesurdoseparrapportàlapopulationgénéraleduGrand-DuchédeLuxembourg,cetteproportion correspondaità5,9décèsparsurdosepour100.000habitantsâgésentre15et64ansen2000(2007: 5,67).En2014,2,04surdosesaiguëspour100.000habitantsontétéenregistrées(2010:3,5),représentant unetendancedécroissante.Lesdonnéesmédico-légalesde1992à2014confirmentquelaquasi-totalité desdécèsimpliquaientlaconsommationd’héroïnesuivisparlessubstancesprescritesdansuncontextede polyconsommation. Pourlesvictimes,ils’agissaitpour2014de87%d’hommesetl’âgemoyenaumomentdudécèsaconnu unehaussediscontinuemaissensiblesurlesdernièresvingtannées(1992:28,4annéeset2014:37,7 années).Bienquelamoyenned’âgeaitaugmenté,lenombredevictimesâgéesdemoinsde20ansestresté relativementstable.Acunevictimemineured’âgeaétérapportéeen2014. Unemajoritéconfirméede75%(75%)devictimesétaitdenationalitéluxembourgeoise.Unedescription détailléedesvictimesdesurdosesfatalesdepuis1994ainsiquel’impactdufacteurgenresurlasurvenude 11 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 surdosesàfaitl’objetd’uneétudeàgrandeéchelledontlesrésultatsontétépubliésentre2013et2015 (Origeretal.,2013,2014,2015)6. CONSÉQUENCES SOCIALES ET MESURES DE RÉINTÉGRATION Lescorollairessociauxdel’usagededroguesetdeladépendanceyassociéesontmultiplesetserépercutent auxniveauxfamilial,professionnel,financieretlégal. Le niveau d’enseignement des usagers recensés est pour la plupart faible et incomplet. Leur situation résidentielle affiche toutefois une amélioration longitudinale. Si en 1995, 31% des usagers disposaient d’unlogementstable,cetteproportionsesitueactuellementautourde72%,cequiestenpartielemérite d’une série de projets d’aide au logement pour personnes dépendantes mis en place dans le cadre des plansd’action«drogues».Leschiffreslesplusrécentstendentcependantàconfirmerquemêmesil’offre enlogementsencadréspourlapopulationviséecontinueàêtredéveloppée,lademandepourcegenrede logementss’estaccrueégalementsurlatoiledefonddelasituationéconomiqueplusdifficiledesdernières années. Le taux de chômage (60%) parmi la population cible tend à stagner. Cependant, la proportion d’UPD professionnellementactifsprésentantunesituationd’emploistableestrestéestableles2dernièresannées, cequidoitégalementêtreappréciéàlalumièredesparamètreséconomiquesactuels. MESURES DE RÉDUCTION DES RISQUES Le nombre de contacts enregistrés par les structures d’accueil bas-seuil et de réduction de risquesaconnuunaccroissementremarquablejusqu’à2010etadiminuépourlapremièrefoisen2011 (2005:47.739/2011:123.465).En2014,lenombredecontactss’élevaità131.375(légèreaugmentation depuis2013).Environ44%desclientsappartiennentàlaclassed’âge25-34anset50%ont35ansou plus.Approximativement15%desclientssontdesfemmes. Depuislamiseenplaceduprogramme national d’échange de seringues,onnotaituneaugmentation continuedunombredeseringuesstérilesdistribuéesjusqu’en2006.Entre2006et2013onassistaitàune tendanceàlabaissealorsqu’en2014unenouvellehausseremarquables’observait(1996:76.259;2013: 190,257;2014:250.552). Letauxglobalderetourdeseringuesuséesaaugmentépendantlapériode deréférenceetsesitueactuellementà94%.Unnombrecroissantd’injecteursseprocurentleursseringues auprès de structures spécialisées suivies des pharmacies et, de moins en moins, auprès des distributeurs automatiques. 12 6 Origer A, Lopes da Costa S, Baumann M.OpiateandcocainerelatedfataloverdosesinLuxembourgfrom1985to2011:Astudy ongenderdifferences.Eur Addict Res.2014;20(2):87-93.DOI:10.1159/000355170 Origer A, Baumann M. OpiateandcocainerelatedFatalOverdosesinLuxembourgfrom1985to2011:atime-stratifiedstudy.21th IUHPEWorldConferenceonHealthPromotion.25-29thAugust2013,Pattaya,Thailand,Volume:HealthIssuesandPopulationsin HealthPromotion. Origer A, Baumann M.SuicideattemptspriortofataldrugoverdoseinLuxembourgfrom1994to2011.21stWorldCongressSocial Psychiatry,29June-3July2013,Lisbon,Portugal,Volume:Thebio-psycho-socialmodel:Thefutureofpsychiatry. Origer A., Bucki B., Baumann, M. Socioeconomic inequalities in fatal opiate and cocaine related overdoses: transgenerational baggageversusindividualattainments.28thConferenceoftheEHPS“Beyondpreventionandintervention:increasingwell-being”, 26th–30thAugust,2014,Innsbrück,Austria. Origer A, Le Bihan E, Baumann M.SocialandeconomicinequalitiesinfatalopiateandcocainerelatedoverdosesinLuxembourg: Acase-controlstudy.Int J Drug Pol2014.25:911-915.DOI:10.1016/j.drugpo.2014.05.015 Origer A, Le Bihan E, Baumann M. (2015)ASocialGradientinFatalOpioidsandCocaineRelatedOverdoses? PLoS ONE 10(5): e0125568. doi:10.1371/journal.pone.0125568 INDICATEURS DE RÉDUCTION DE L’OFFRE7 D’importantesvariationsauniveaudel’évolutiondesquantités saisiess’observentdepuisledébutdes années90etcecipourpresquetouslestypesdeproduits.Uneanalyselongitudinaleindiqueunetendance généraleàlabaisse8desquantitésd’héroïne,decocaïneetderésinedecannabisaffichanttoutefoisune haussepourles3substancesen2014. Lenombrededélinquantsimpliquésspécifiquementdansletraficillicitededrogueamontréunetendance généraleàlahaussejusqu’à2002etmontredepuislorsunetendanceàlabaisse.Laquantitédecannabis saisieaaugmentéen2014.Nonobstantlesquantitésdecannabisetdecocaïnesaisies,lenombredesaisies aaugmentédefaçondiscontinuedepuis1990.Cecisuggèrequ’unnombreplusélevédesaisiescomportant desquantitésréduitesaétéenregistré.Depuis2008,lenombredesaisiesdecannabisaaugmenté,tandis quelenombredesaisiesd’héroïneadiminuédefaçondiscontinue.Aussi,lenombretotaldepersonnes impliquées dans les saisies a montré une tendance générale à la baisse. Le nombre total de personnes impliquées dans des infractions de détention de drogues a montré une augmentation continue. (2000 : 1.758;2013:2.069;2014:2.816). 2015 Saisies de substances illicites au niveau national Aucunesaisiedecrackn’aétérapportéeàcejourparlesinstancesrépressivesbienquelesassociationsde terrainrapportentlapratiquedufree-basing / cocaine cookingparcertainsusagers. LespremièressaisiesdesubstancesdetypeXTContétéenregistréesen1994.Ladisponibilitédel’ecstasy estrestéestabledepuis1996alorsquelessaisiesaffichaientunenettehausseen2009pourdiminuerà nouveaulesdernièresannées. Lenombredeprocès-verbauxpourmotifsd’infractionàlaloimodifiéede1973estpasséde764en1995 à2.792en2014.Encequiconcernelenombrerespectifdeprévenus,onnoteuneévolutionsimilaireà celledunombredeprocès-verbaux.En2014furentenregistrées167arrestations(2006:225)pourmotifs d’infractionàlaloimodifiéede1973. La population des prévenus se compose de 82% d’hommes, proportion qui variait entre 79% et 90% durant les dix dernières années. 808 prévenus nouveaux ont été enregistrés en 2003 ; 854 en 2013 et 1.066en2014.Lepourcentage de prévenus mineurs (<18ans)parmilespremiersauteursaconnuune notabletendanceàlahausseentre2010(18,7%)et2014(22,2%).Lecannabisestlaprincipalesubstance impliquéedanslespremièresinfractions. Depuis1998,lespersonnesoriginairesdepaysautresqueleLuxembourg(50%en2014)ontreprésentéla majoritédesprévenus(52-68%).38%(41%en2013)descasenregistréssontdespremiersauteurs. Lesdonnéesstatistiquesfourniesparl’administrationpénitentiairepourl’année2014fontétatde904(950 en2012;818en2013)nouvellesentréesauCPLdont223(24,67%)pourinfraction(s)àlaloimodifiéedu 19février1973(Code:DELIT-STUP);uneproportionquireprésentait42,6%en1996. 7 8 Sauf indication contraire, les données présentées se rapportent à l’année 2014. A défaut d’autres indications, les données entre parenthèsesserapportentàl’année2013. Lesdroguesentransitexclues;uniquementlesquantitésdestinéesaumarchénational. 13 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 DISPONIBILITÉ ET QUALITÉ DES DROGUES ILLICITES AU NIVEAU NATIONAL Laproductionnationalededroguesillicitesestjugéetrèslimitéeentermesdequantitéetdequalité.En 2014,aucunlaboratoireclandestindedroguesn’aétédémantelé.SelonlesdonnéesfourniesparlaPolice Judiciaire et par l’ensemble des unités décentralisées de la Police Grand-Ducale (sections de recherche), lagrandemajoritédesdroguesillicitesconsomméesauGrand-DuchédeLuxembourgsontoriginairesdes Pays-Bas(productiondecannabisettransitd’autresdrogues)suivisdelaBelgique(productiond’ecstasyet d’amphétamines)etduMaroc(productiondecannabis).L’importationdecocaïnedepuisl’Amériquelatine s’effectuesouventparlesuddel’Europe(Espagne,Portugal)pourêtreacheminéeensuitevialaFrance,la Suisse,l’Autricheetl’AllemagneendirectiondesPays-Bas,tandisquel’héroïnecontinueàemprunterlaroute duBalkan(RoumanieetBulgarie)oudesdérivésdecelle-ci(Pologne,Turquie,Bélarusse).Lepaysproducteur principalrestel’Afghanistan. Aucoursdesdernièresannéesdesréseauxdedistributionmieuxorganisésontvulejoursurleplannational. L’expansiondecesréseauxplusstructurésacontribuéàunehaussesensibledeladisponibilitédedrogues, particulièrementencequiconcernel’offredecocaïneetdecannabis.Lesnouvellesdroguessynthétiqueset produitsasscociés(Legalhighs)sontàsurveillerdefaçonrapprochée.Lesstratégiesettechniquesdevente de drogues impliquent plusieurs acteurs avec des tâches bien définies afin de réduire les risques liés au trafic.Parailleurs,lesréseauxdeventeœuvrentàdélocaliserleurspointsdeventeversdesendroitsmoins visiblesauxforcesdel’ordre,telsqu’appartementsprivésoucafés.Laproportiondetrafiquantsdedrogues non-luxembourgeoisestrestéestablelesdernièresannées. AuvudelapositiongéographiqueduLuxembourg,laPoliceGrand-Ducaletravailleenétroitecollaboration avecsespaysvoisinsetlesPays-Bas.Danslecadred’accordsdecoopérationpolicièreinternationale,des opérationsàgrandeéchellesontrégulièrementorganiséesafindeluttercontreletraficdedrogues.Dansle cadredecesopérations,laPolicemetenplaceundispositifdesurveillance,d’observationetd’interpellation afindecombattrelesfluxillicitesdestupéfiantsenprovenancedesPays-Basetlesphénomènesdetraficet deconsommationrégionaledestupéfiants. Comparéeàlasituationde2006,la puretédelacocaïneabaisséetdesvariationsremarquablesdela pureté moyenne de l’héroïne ont été observées ces dernières années. La concentration moyenne de THC détectéedansdesproduitsducannabisafficheunetendanceàlahaussedepuisplusieursannées. Ils’agiradesuivreattentivementlesvariationsimportantesauniveaudespuretésminimalesetmaximaleset plusparticulièrementlesconcentrationsdeTHCdansdifférentesvariétésdecannabissaisiesauLuxembourg. Les prixderuedel’héroïne,delacocaïneetducannabisconnaissentdesmargescroissantes,cequiest dûpartiellementauxdifférencesdeplusenplusmarquéesdelaqualitédel’ensembledesdroguesderue. TENDANCES ESSENTIELLES Tousindicateursdetendancesconfondus,lesdonnéeslesplusrécentesconfirmentune stabilisation de la prévalence d’usagers problématiques de drogues et d’usagers intraveineux au Grand-Duché de Luxembourg. Aucoursde ladernièredécennieunnombrecroissantd’UPDacommencéuntraitement ouprofitedesoffresbas-seuiletunnombredécroissantd’UPDentreencontactaveclesforcesdel’ordre. 14 La qualité des drogues vendues sur les marchés illicites au niveau national a connu une dégradation importante,cequiaeucommeconséquenceuneaugmentationgénéraliséedelapolyconsommation.Le nombredevictimesdesurdosagesmortelsadiminuédepuis2007(27cas)pouratteindre8casen2014. BienquelaprévalenceUPDrécentetémoigned’unetendanceàlabaisse,denouveauxphénomènessont apparusdontl’ivresseprécoce,le«bingedrinking»chezlesjeunes,le«cocainefreebasing»etl’usagede nouvelles drogues de synthèse (NPS) et de produits contenant ces dernières. Ces nouveaux phénomènes doiventêtreobservésdeprèsaussienraisondel’impactimportantqu’ilspeuventavoirsurl’incidenceUPD àl’avenir. 2015 L’usage intraveineux d’héroïne et de cocaïne associé à une polyconsommation demeure le mode de consommation préférentiel des usagers répertoriés par le réseau institutionnel. Toutefois la pratique de l’inhalation(chasing)gagneprogressivementduterrainsurl’usageintraveineux. Les maladies infectieuses dont souffrent beaucoup d’usagers de drogues et particulièrement les UDVI demeurentunphénomènepréoccupant.LaproportiondesUPDinfectésparleVIH,restéestablede2000 à2008,amontréunetendanceàlahausseentre2009et2010,poursestabiliserànouveauautourde3 à5%entre2011et2014.Onobservetoutefoisunehaussedelaproportiond’injecteursdedroguesdans lescasVIHnouvellementdiagnostiquésdepuis2013.L’infectionàl’hépatiteC,affichantunetendanceà lahausseentre2000et2008,alégèrementdiminuéen2009et2010,ainsiqu’en2012,pouraugmenter à nouveau en 2014. Des résultats de recherche basés sur des tests de dépistage sérologiques (Origer & Removille, 2009) ont suggéré des proportions d’infectionàl’hépatiteCdeplusde70%etplusélevées encoreauprèsdespersonnesdétenuesdanslesétablissementspénitentiairesen2007. Le marché illicite au niveau national se caractérise par des techniques de vente et de stratégies de distribution plus agressives ce qui est notamment dû à une collaboration plus perfectionnée entre des groupescriminelsd’originesethniquesdifférentesquiauparavantontopérédefaçonindépendante.Dansce contexteonaobservéquelespointsdeventesontdevenusmoinsvisiblespourlesforcesdel’ordre,p.ex.des appartementsprivésoudesbars.Uneattentionparticulièredoitaussiêtreportéesurlesdifférencesaccrues observéesdanslespuretésminimalesetmaximalesdesdroguesderueainsiqu’àlaconcentrationmaximale du THC au niveau des saisies de cannabis les dernières années. Les différences de qualité des drogues de rue ont tendance à augmenter ce qui suggère des mécanismes plus diversifiés de distribution et qui pourraitexpliquerlesvariationsdepriximportantesobservéesaucoursdesdernièresannées.L’ensembledes indicateursdisponiblessuggèreparailleursquelesconsommateursdedroguesillicitess’approvisionnentde plusenplussurlemarchénational. Les développements en termes de réponses apportées aux problèmes associés à l’usage problématique dedroguessontàmettreenliendirectaveclamiseenexécutiondelastratégienationale«drogueset addictions»etdesplansd’actionyassociés.Aucoursdesdernièresannées,lesservicesdeconsultationet detraitementspécialisésontétélargementadaptésauxréalitésobservéesetauxdéfisnouveaux,cequiaeu commeconséquencepositivequeplusdepersonnescommencentleur premier traitement à un moment plus précoce de leur carrière d’usager. Une planification pluriannuelle concertée a permis par lebiaisdeplansd’actionconcretsettransparentsd’atteindreunemobilisationderessourcesbudgétaires significativementplusélevéesquelorsdesannéesprécédantcettepremière.Silapréventionprimaireest aupremierplan,onretiendraégalementdesaméliorationsvisiblesauniveaudesmesuresd’intervention précoce. Des efforts importants ont par ailleurs été entrepris au niveau des mesures de réduction de risques et dommages et de la diversification des offres de prise en charge. Les mesures de réintégration socioprofessionnelleontportéleursfruitsauvudesdonnéesrécentesenlamatière.L’offredetraitementde substitution,etlesstructuresderéductionderisquessesontdéveloppéesetcontinuentàsedéveloppersur latoiledefonddeladécentralisationàl’échellenationale. 15 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Au cours des années récentes, le nombre croissant de clients en traitement contraste avec un nombre décroissantdeprévenuspourinfraction(s)àlalégislationenmatièrededrogues.Onretiendraégalement une diminution des traitements aigus en milieu hospitalier au bénéfice des traitements spécialisés extrahospitaliersetdestraitementsdesubstitution. Des mécanismes de coordination ont été renforcés entre les ONG et les autorités nationales et des mécanismesd’évaluationsontenplace.Ilaétéprocédéàunedeuxièmeévaluationexternedupland’action droguesetaddictions(2010-2014).Lesrésultatsontétéintégrés,ensembleaveclesrecommandationsissues d’unesériedegroupesdetravaild’expertsnationauxetderésultatsd’enquêtesauprèsdesusagers/clients, dansl’élaborationdelanouvellestratégiedroguesetaddictionsetpland’action2015-2019quiasontour serasoumisàuneévaluationexterne. CONCORDANCE ENTRE INDICATEURS Lesindicateursderéductiondelademandeconcordentmajoritairementaveclesdonnéesdelaréduction del’offre.LaplupartdesindicateursindirectsdeprévalenceUPDreflètentaussilestendancesdocumentées parlesétudesnationalesdeprévalence. Lenombreabsoludesurdosesfatalesaatteintunniveauplusbascomparéauxannéesprécédentes.Ildoit être noté que des changements au niveau de chiffres absolus peu élevés peuvent induire des variations nonnégligeablesauniveaudespourcentagesetqu’unecomparaisondestauxdesurdosagesaucoursdes dernièresannéespermetd’entrevoirplusclairementlatendanceactuelleàlabaisse. 16 ANNUALNATIONALREPORTONTHESTATEOFTHEDRUGSPROBLEM (Edition 2015) DRUG POLICY : LEGISLATION, STRATEGIES AND ECONOMIC ANALYSIS In 1999 the government entrusted the Ministry of Health with the overall coordination of drug-related demandandriskreductionactions.Thisledtothecreationofthenationaldrugcoordinator’sofficein2000. 2015 SUMMARY The2009governmentalprogrammehassettheframeworkfortheelaborationofthethirdnationalstrategy and action plan (2010-2014) for the fight against drugs and addictions. The national strategy and action plan 2010-2014 reliedupontheprioritiesoftheMinistryofHealthandasustainedcollaboration withfieldactorsandcivilsociety.Inordertooptimizeitsimpact,thenewactionplanhastakenintoaccount relevantissuesfromEUandECtreaties, the EU anti-drugs strategy 2005-2012andtheEU drugs action plans 2009-2012. The elaboration of the new national drugs action 2015-2019 has build upontheoutcomeofanexternal evaluationofthepreviousactionplan.Thegeneralaimofthenational strategyandactionplanistocontributetoahighlevelofprotectionintermsofpublichealth,publicsecurity andsocialcohesion. Thenationaldrugstrategyreliesontwo pillars,namelyondemandreductionandsupplyreductionand on four transversal axes: 1. Risk, damage and nuisance reduction, 2. Research and information, 3. International relations and 4. Coordination mechanisms. The national drug coordinator, jointly with the InterministerialCommitteeonDrugs(ICD),followsupandsteerstheimplementationprocessofthenational drugsactionplan. Theglobal budget of the Ministry of Healthgrantedtodrugdemandreductionrelatedservicesand programswentupfrom2,066,000.-EURin2000to10,949,211.-EURin2014,thuswitnessingaprogression rateof430%.Overallpublicexpendituresinthefieldofdrugdemandanddrugsupplyreductionperyear are currently estimated at 38,500,000.- EUR (Origer, 2010). Expenditures exclusively allocated to drugrelatedtreatmentreached16,231,609.-EURin2012. EPIDEMIOLOGICAL INDICATORS Globally,UNODC9(2015)estimatesthat,246millionpeopleaged15to64yearsusedatleastoneillicit substanceduringthepastyear,meaning1personoutof20fromthisagegroup. Problematicdruguseconcernssome270millionpeople;halfofthemareintravenousdrugusers.L’UNODC estimatesthat1,65millionofintravenousdrugusersareHIV+. Cannabis remains the most widely consumed drug worldwide (177.63 million people or 3.8% of the populationaged15to64years)whichrepresentsaslightincreasecomparedtotheestimationsof2009. Theuseofamphetamine-typestimulantsreached34.40millionpeople(0.7%).Theprevalenceof“ecstasy” (18.75%millionpeopleor0.4%ofthepopulationaged15to64years)hasdecreasedcomparedto2009 data.Thenumberofopiateusershasstabilisedandsituatesaround16.5millionpeople(0.435%). AccordingtotheEuropeanDrugReport2014publishedbytheEMCDDA,80millionpeoplehaveusedan illicitdruginEurope.Positiveevolutionsaretobeseeninthedeclineofnewheroinusers,thedecreaseofthe 9 Extracts from the World Drug Report 2014 (UNODC, 2015) 17 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 numberofpeoplewhoinjectdrugs,thereductionofthemortalityassociatedtodruguseandthedecrease oftheuseofcannabisandcocaineinseveralcountries.Inaddition,recordlevelsofthenumberofpeople intreatmenthavebeenobserved(1.2millionofEuropeansin2011)aswellasacontinuingdecreaseofthe HIVinfectionassociatedtodruguse.Amphetaminesandecstasyremainthesyntheticstimulantsmostly usedinEurope.Recentdatasuggest,however,astableanddeclininguseofamphetaminesbyyoungadults. Concerningcannabis,around1%ofEuropeanadultsareestimatedtousecannabisdailyornearlyona dailybasis.11,7%ofyoungEuropeans,aged15to34yearshageconsumedcannabisduringthepastyear. Also the number, type and availability of new substances in Europe continue to increase. Globalization mechanisms,technicalprogressandtheuseoftheinternethavecontributedtoamarketopenfornewdrugs mostlyofsyntheticorigin. Atthemicrogeographicallevel,tendanciesobservedintheGrand-DuchyofLuxembourgreflectentthose observedintheEUwithlocalprevalenevariationsandageneralreductionoftheprevalenceofproblematic druguse. National drug prevalence in the general population Drug prevalence in school population and in general population Serialschoolsurveydata(HBSC1999–2010)revealadecreaseintheprevalenceofanyillicitdrugusefrom theendofthe20thcenturyto2010.In-depthanalysisshowsanoveralldeclineinprevalencebetween1999 and2006andafairstabilizationafterwards.Allcommonillicitdrugsfollowdecliningprevalencetrends withthenotableexceptionofcocainewitnessinganincrease,particularlyintheagegroup15to16years. Opiates’useinschool-agedchildrenhasbeenconsistentlylowoverthelastdecade. Eventhoughcannabisisstillthemostusedillicitdrugbyyoungstersaged12to18years,anobviousdecline hasbeenobservedfromthebeginningofthe21stcenturyasfaraslifetimeprevalenceisconcerned.Recent andcurrentcannabisuseprevalencerateshavebeendecliningremarkablybetween1999and2006and seemtohavestabilisedsincethen. Also,themeanageatfirstuseofcannabisandillicitdrugsingeneralhasincreased(+/-6months)between 2006and2010.In2010,9.44%ofyoungstersaged15yearsreportedfirstcannabisusebeforehaving reached15years,whereasthissameproportionfigured12.03%in2006. Anongoingsurvey(EuropeanHealthInterviewSurvey)willprovidenewprevalencedatainthebeginning of2016. National prevalence of problem drug use (PDU) Data on institutional contacts and drug treatment demands Theannualnumber of PDU person-contactsindexedbynationalinstitutionsfigured5,80610in2014 (2002:4,701). 10 Inthisfiguredoublecountingisincludedmeaningthatagivenpersoncouldhavebeenindexedtwiceormorebydifferentinstitutions. Itisthusnotrepresentingtheactualprevalence,whichhastobeassessedbyothermethods. 18 2015 2,383usershavebeenindexedbynationalspecialiseddrugdemandreductionagenciesand2,318druglaw offendersbysupplyreductionagenciesin2002.In2014, thesameagencieshaveindexed2,791and3,015 personsrespectively.Overallthenumberofpersonsshowingdrug-relatedcontactswithDRorSRagencies hasdiscontinuouslyincreaseduntil2010andwitnessesafirstdecreasein2011confirmedby2014data. In2014anincreaseofcontactsregisteredbysupplyreductionagenciesisnoted.Thepreviousdecreaseis primarilyduetoadecreaseofthenumberofcontactswithlawenforcementagencies.Also,thenumberof inpatientdrugtreatmentdemandersinhospitalcaresettingshasbeendecreasinginrecentyears,whereas specialised non-hospital based treatment and substitution treatment have gained in importance. Worth mentioningisalsothedecreasebetween2011and2013ofnationallowthresholdagencies’contacts.Anew increasehasbeennotedin2014. Socio-demographic profile of PDU Themale/female ratioofthePDUpopulationcurrentlysetsat4:1.Overthelastdecadetheproportion ofindexednon-nativePDUhasbeenshowingstrongvariationsbutaclearlyincreasingtrendsince2003 hasbeenshowingsignsofstabilisationfrom2008to2014.Thepopulationofnon-nativedruguserslargely consistsofPortuguesenationals(32%oftotalnumberofnon-nativePDU),representingaproportionthat iscomparabletotheoneobservedinthegeneralpopulation(36.5%).CitizensofAfricanandFrenchorigins occupythesecond(24%)andthird(11%)rankrespectively.Belgiancitizensrankat4thpositiontogether withGermancitizens(5%). Themean ageofindexedPDUhasbeenevolvingfrom28yearsand4monthsin1995to32yearsand 3monthsin2014.MeanageofmalePDUhasbeenincreasingfasterthanforfemales.Thegapbetween youngestandoldestPDUhasbeenstabilisedinrecentyears,afteryearsofincreaseasoneobservedalongtermincreaseofthepopulationofPDUaged40yearsandmoreandasensitivedecreaseinPDUagedless than30years.ThemeanageofnativePDUisconsistentlylowerthantheoneobservedfornon-natives. Worthmentioningisalsothesignificantincreaseoftheaverageageofoverdosevictimsoverthelastdecade andanincreaseoftheproportionofminorsamongdruglawoffendersoverthelastfouryears(2014:9%, 2013:11%,2012:10%,2009:6%). Problem drug use prevalence and consume trends NationaldataareprovidedbyserialprevalencestudiesonPDUagedbetween15and64yearsperformed in1997,1999,2000,2007and2009data(Origer,2012)11.Theestimationstudyon2009dataprovidesan absoluteprevalenceofproblemdrugusers(PDU)of2,070persons(C.I.(95%):1,553to2,623).Intermsof prevalenceratesestimatesforthesameagecategories,6.16outof1,000habitantsagedbetween15and 64yearsshowproblemdruguse.Accordingtoavailableserialdatafortheyears1997to2009,absolute prevalenceandprevalenceratesofPDUhavebeenshowinganincreasingtrenduntil2000.Afterabrief plateau,adecreasehasbeenobservedfrom2003onwards.Absoluteprevalenceandprevalenceratesof intravenousdruguse(IDU)inthenationalpopulationaged15to64yearshavebeenincreasingbetween 1997and2007toshowfirstsignsofdeclinein2009. Injecting heroin useassociatedtopoly-drug usehasbeenreportedbeingthemostcommonconsume patterninPDU.Theratioofinjectingopiates’usetotheinhalation modehasreached3:2in2014.The prevalenceoftheuseofcocaineasprimarydrugincreaseduntil2006andfromthereondiscontinuously decreased.In2014,cocaineasprimarydrugshowedanincrease(19.9%)asin2013(17.3%). 11 Origer A. PrevalenceofProblemDrugUseandInjectingDrugUseinLuxembourg:ALongitudinalandMethodologicalPerspective. Eur Addict Res.2012;18:288-296. 19 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Thenumberofpersonsincontactwiththenationalspecialisednetworkfor(preferential)cannabisuse currentlyrepresents25.5%(31,1%).Amphetamine typesubstancesandecstasyrelatedtreatmentdemands areonlyweaklyrepresented,which,however,doesnotinformontheirprevalenceingeneralpopulationas RELISdatarefertoPDUandnottotheoverallpopulationofrecreationaldrugusers.Theproportionofpolydrug usehasbeendecreasing2011onwardswithincreasingtrendsin2014(54%). DRUG-RELATED TREATMENT Thenumberofadultoutpatientclientstendstostabilisewhileadultinpatientdecreaseandout-patient minor treatment demanders have been continually increasing. Since 2010 the number of substitution treatment demanders has been stabilising and the number of contacts in low threshold facilities (2013: 124,048; 2012:127,080; 2010: 140,093 contacts) has been decreasing from 2010 to 2013. In 2014 the numberofcontactsinlowthresholdfacilitiesincreasedagainto131,375contacts.In2014,aproximately 12.5%ofrespondentshavebeenfirsttreatmentdemanders,alltreatmentcentresincluded.Aconfirmed trendhastobeseeninthedecreaseoftheproportionofsubstitutionpatientsagedlessthan25yearsand theincreaseoftheproportionofpatientsaged40yearsandmore. HEALTH CORRELATES AND RESPONSES TO CONSEQUENCES TheHIV/AIDS prevalence12inPDUhasbeenstablein2014,andtheinfection of HCV (hepatitis C) hasremainedstablein2014,comparedto2013data.DatafromtheNationalLaboratoryofRetrovirology suggest a long term and discontinuous decreasing tendency of the average proportion of IDU in newly diagnosedHIVcases.From2004to2008thisproportionhasbeenvaryingbetween7and14%,following anincreasingtrenduntil2014.HIVinfectionratesinIDUsituatedaround5percent,whichstandsfora stabilisation,comparedto2013data. The implementation of the 2005-2009 and 2010-2014 action plans has been accompanied by a discontinuousbutsignificantoveralldecreaseoffataloverdose casesintheGrandDuchyofLuxembourg (2014:8cases). IntermsofnumberofoverdosecasesinthegeneralpopulationoftheGrandDuchyofLuxembourg,this proportionfigured5.9overdosedeathsper100,000inhabitantsaged15to64yearsin2000(2007:5.67 casesper100,000inhabitants).In2014,2.04acuteODcasesper100,000inhabitantshavebeenregistered (2010:3.5),showingadecreasingtendency.Forensicdatafrom1992to2014showthatthemostfrequently involvedsubstanceindrug-relateddeathisheroin,followedbyprescriptiondrugsconsumedinapolyuse context.7victimsweremale(87%)in2014andthemeanageofvictimshasbeenshowingadiscontinued increaseoverthepast20years(in1992:28.4yearsandin2014:37.7years).Althoughthemeanageof drugoverdosevictimshasbeenincreasing,thenumberofvictimsagedlessthan20yearshasremained relativelyunchanged.Nounderagevictimwasreportedin2014. Asregardsthenationalityofoverdosevictims,75%(75%)werenatives. 12 Origer A., Schmit J.-C.PrevalenceofhepatitisBandCandHIVinfectionsamongproblemdrugusersinLuxembourg:self-report versusserologicalevidence.J Epidemiol Community Healthdoi:10.1136/jech.2009.101378 20 Socialcorrelatesofproblemdrugusearemanifoldandtouchuponfamily,professional,financialandlegal areas. TheeducationallevelsofPDUarelowandmostlyincomplete.Theresidential statusofthelatterhas improvedoverthelastyears.In1995,31%oftheusersreportedstableaccommodation;currentlythesame proportionsituatesat72%.Thisimprovementispartlyduetovariousaccommodationandhousingoffers foraddictedpeoplesetupintheframeworkofthedrugactionplan.Recentfigurestendtoconfirmthat althoughspecialisedaccommodationoffershavebeenfurtherdeveloped,thecurrenteconomicsituationhas createdanevenhigherdemandforthistypeofhousing. 2015 SOCIAL CORRELATES AND SOCIAL REINTEGRATION Theunemployment rate (60%)tendstoplateau.However,theproportionofactiverespondentsreporting astablejobsituation(e.g.longtermcontract)isstableoverthelast2years,whichshouldalsobeputinthe contextofthecurrenteconomicparameters. HARM REDUCTION ACTIVITIES Thenumber of contactsindexedbynationallow-thresholdagencieshasbeenincreasingmarkedlyuntil 2010anddecreasedforthefirsttimein2011(2011:123,465/2005:47,739).In2014,131,375contacts havebeenregistered(slightincreasecomparedto2013).Approximately44%ofclientsareagedbetween 25and34years,and50%ofclientsaged35andmoreisobserved.Around15%ofclientsarefemales. Thenumberofsyringesdistributedintheframeworkofthenationalneedleexchangeprogramme(2014: 250,552/1996:76,259),peakedin2006andhasbeendecreasingdiscontinuouslyonwards.Returnrates ofusedsyringeshavebeenincreasingduringthereferredperiodandreached94%in2014.Anincreasing majorityofinjectorsprocuretheirsyringesinspecialisedagenciesfollowedbypharmaciesanddecreasingly viaautomaticdispensers. LAW ENFORCEMENT INDICATORS13 Seizures of illicit substances at the national level Greatvariationshavebeenobservedastothequantity of illicit substances seizedsincethebeginning ofthenineties.Alongitudinaldataanalysisfrom2000onwardsindicatesageneraldecreasingtendency in heroin and cocaine seizures, whereas cannabis (herbal and resin) seizures14 have been showing a discontinuous increase. Quantities of herbal cannabis seized have increased compared to the situation observedinyear2000. The total number of persons involved in traffic has followed a constant upward trend until 2002 and showedadecreasingtrendlinesincethen.Quantitiesofseizedcannabiswentupin2014.Notwithstanding the quantities of cannabis and cocaine seized; the number of seizures has grown discontinuously since 1990.Thissuggeststhatmoreseizuresofsmallerquantitieshavebeenreported.Since2008thenumber ofcannabisseizureshasclearlyincreased,whilethenumberofheroinseizuresdiscontinuouslydecreased. Also,thenumberofoffendersinvolvedinseizureshasbeenshowinganoveralldecreasingtrend.Thetotal number of personsinvolvedindrugpossessionhasfollowedaconstantupwardtrend(2000:1,758,2012: 1,782,2013:2,069persons;2014:2,816). 13 Ifnotspecified,datareferto2014.Figuresinbracketsreferto2013ifnototherwisespecified. 14 Non–transitdrugsdestinedtothenationalmarket 21 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Crack(cocaine-base)seizureshavenotbeenreportedtodatebynationalauthorities,althoughfreebasing isreportedbyfieldagencies.Thefirstnationalseizuresofecstasy type substances(MDMA,MDA,etc.) wererecordedin1994.Theavailabilityofecstasyhasbeenstablesince1996butseizedquantitiesincreased remarkablyin2009followedbyadecreaseinthepastyears. Drug law offenders and prison sentences Thenumber of police recordsforpresumedoffencesagainstthemodifieddruglawof1973wentfrom 764in1995to2,792in2014.Asimilarevolutionhasbeenobservedwithregardtothenumber of drug law offenders.In2014,167arrests (225in2006)forpresumeddrugoffenceshavebeenreported. The population of drug law offenders is composed of 82% males; a proportion that has been varying between79%and90%duringthepastdecade.808first drug law offenderswerereportedin2003and 1,066in2014.Alsothepercentage of minors(<18years)amongfirstdruglawoffendershasremarkably increased:1994(4.9%)2000(8.7%)2014(8.5%).Cannabisisthemaindruginvolvedinregisteredfirst drugoffences. Since1998,non-natives (50%in2014; 48%in2013)havebeenrepresentingthemajorityofdruglaw offenders(52-68%).38%(41%in2013)oftheregisteredcaseswerefirst drug law offenders. National prison dataof2014referto904(818)newadmissionsofwhich223(24.67%)wererelatedtodruglaw offences;aproportionthatrepresented42.6%in1996. PROFILE OF THE NATIONAL DRUG MARKET The national production and culture of illicit drugs appears to be irrelevant in terms of quantities and quality.In2014noclandestinedrug-manufacturinglaboratoryhasbeendismantledatthenationallevel. AccordingtoobservationaldataprovidedbytheJudicialPoliceandalldecentralisednationalpoliceunits, amajorityofillicitdrugsconsumedintheG.-D.ofLuxembourgoriginatefromtheNetherlands(cannabis production and transit of other drugs), followed by Belgium (ecstasy and ATS production) and Morocco (cannabisproduction).CocainefoundonthenationalmarketisoriginatingfromLatinAmericaandmostly transits South of Europe (Spain, Portugal) to reach the Netherlands via France, Switzerland, Austria and Germany.HeroinfollowsthemainBalkanrouteanditsderivate(Poland,Turkey,Belorussia). In recentyears moreorganised distribution networkshavebeendevelopingnationally.Theexpansionof these structured distribution networks by criminal associations thus contributed to a significant increase indrugavailability,andparticularlyinthesupplyofcocaineandcannabis.Dealingandsellingtechniques involveseveralactorstominimisetraffic-relatedrisk.Moreover,ithasbeennotedthattraffickerstendto delocalizetheirsellingpointstolocationsorsettingslessvisibleforpoliceasforinstanceprivateflats,bars ormotorwayrestareasinordertomeettheirclientshalfwayandsellgrossquantities.Theproportionof non-nativesinvolvedindrugtraffickinghasbeenstableinrecentyears. Comparedtothesituationin2006,purityofcocainehasbeendecreasingandremarkablevariationsin averageheroinpuritywasobservedoverthepastyears.Attentionhastobepaidtothestrikingdifferences inmaximumandminimumpuritiesaswellastoahighmaximumconcentrationofTHCincannabisproducts seizedinLuxembourginrecentyears.Pricesmovewithinincreasinglybroaderrangesforheroin,cocaine andcannabis,whichispartlyduetoincreasingdifferencesinqualitylevelsofstreetdrugs. 22 All indicators included, a decrease in PDU prevalence rates has been observed over recent years and resultsfromlatestprevalencestudiessuggestthatIDUprevalencehasstabilised.Overthelastdecadean increasingnumberofPDUenteredtreatmentoruselow-thresholdoffersandfewercameincontactwith lawenforcementagencies. Injectingopiateuse,combinedwithpolyuse,isthepredominantPDUpattern.However,recentdatasuggest thattheinhalationmode(chasing)aswellastheinjectionofcocaïnearebecomingincreasinglypopular.The overallqualityofstreetdrugsdecreased,whichresultedinanoverallincreaseofpolydruguse.Thenumber ofacutedrugdeathswentdownto8casesin2014(27casesin2007). 2015 MOST RELEVANT TRENDS AlthoughcurrentPDUprevalenceshowsadecreasingtrend,newphenomenasuchasearlydrunkenness, bingedrinkinginyoungsters,cocainefreebasing,stimulants’injectionanduseofnewsyntheticdrugsand productscontainingthelattermustbemonitoredcloselysincetheymayhavearelevantimpactofPDU incidenceinthefuture. ThereisalsogreatconcernaboutinfectiousdiseasesindrugusersandparticularlyinIDUs.HIVratesin PDUs have been low and stable from 2000 to 2008, but showed an increasing tendency in 2009 and 2010,tostabiliseagainaround3to5%between2011and2014.However,theproportionofIDUsinnewly detectedHIVcaseshasbeenincreasingsince2014,hepatitisCprevalencehasbeenincreasingcontinuously from2000to2008,slightlydecreasingin2009and2010,aswellasin2012toincreaseagainin2014. Latest research results based on serological testing (Origer & Removille, 2009) suggested HCV infection ratesover70%andevenhigherprevalenceratesinprisonpopulationsin2007. Thenationaldrugmarketisledbymoreaggressivesellinganddistributiontechniquestrategiesaswellas improved strategies of trafficking involving ‘multiplayers’ with specific tasks. A tendency to move selling pointstolocationsorsettingslessvisibleforpoliceasforinstanceprivateflatsorbarsisalsoobservedin thiscontext.Attentionhasfinallytobepaidtothestrikingdifferencesinmaximumandminimumpurities ofstreetdrugsaswellastoahistoricallyhighmaximumconcentrationofTHCincannabissamplesseized overthelastyears.Qualityrangesofstreetdrugstendtoincreasewhichsuggestmorediversifieddistribution mechanisms and may explain the important price variations observed during recent years. Available indicatorssuggestthatusersincreasinglyacquireillicitdrugsonthenationalmarket. Themostrelevantdevelopmentsattheresponsesideresultfromtheimplementationofthenationaldrug strategy and its associated action plans. Over the last years, counselling and specialised care networks havebeendeveloped,whichhadasapositiveanddocumentedconsequencethatPDUstarttreatmentat anearlystageoftheirdrugcareer.Drugactionplanshavealloweddisposingoffinancialmeansthathave knownanimportantincreasecomparedtothetimeprecedingdrugactionplans.Ifprimarypreventionis considered most important, there have been visible improvements in early intervention measures. Major effortshavealsobeenmadeinthediversificationofcareoffersandfinallyharmreductionmeasureshave beensignificantlydeveloped.Housingoffersandreintegrationprogrammeshaveobviouslycontributedto improvesocio-professionalsituationsasdocumentedbylatestRELISdata.Substitutiontreatmentandlowthresholdoffershavebeendecentralisedandcontinuetobeso. Inrecentyears,anincreasingnumberofdrugusersintreatmentcontrastwithadecreasingnumberofdrug lawoffenders.Moreover,treatmentepisodesinhospitalsettingshavebeendropping,whereas,specialised outpatienttreatmentandsubstitutiontreatmentdemandshavebeenincreasinginrecentyears. Coordination mechanisms have been reinforced between NGOs and national authorities and evaluation mechanismsareinplace.Asecondexternalevaluationofthenationaldrugsactionplanhasbeenperformed andoutcomeshavebeenintegratedtogetherwithrecommendationsfromaseriesofnationalexpertgroups andoutcomesofusers/clientssurveysintheelaborationofthenewdrugsstrategyandactionplan20152019. 23 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 CONSISTENCY BETWEEN INDICATORS Demandreductionindicatorsaremostlyconsistentwithsupplyreductiondata.MostindirectPDUprevalence indicatorsalsoreflecttrendsdocumentedbyin-depthPDUstudies. Moreover,theabsolutenumberoffataloverdoseshasreachedalowerlevelcomparedtopreviousyears. Itshouldbestressedthatchangesinsmallfiguresmayproducegreatvariationsinpercentagesandthat comparisonofoverdoseratesovertheyearsmakethedownwardtrendmoreobvious. Admission statistics in low-threshold drug agencies depend of course on the capacities of low-threshold offersandthelevelofaccesstoharmreductionmeasuresatthenationallevel.Thissaideventhoughharm reductionoffershavebeenfurtherdevelopedinLuxembourg,thenumberofcontactswiththelattertendto decreasecomparedtothesituationobservedinyear2010. 24 NEW DEVELOPMENTS AND TRENDS 1. DRUG POLICY: LEGISLATION, STRATEGIES AND ECONOMIC ANALYSIS INTRODUCTION 2015 PART A: Giventhecomplexnatureofdruguseanditscorrelates,nationaldrugpoliciesarebasedonsharedpolitical competenciesandresponsibilities.Furthermore,intermsofinterventionstrategies,themoreholisticconcept ofaddictivebehaviourhasgainedinimportanceandinfluencesincreasinglypolicydebates.Thistendency isreflectedbytheenlargementofICD(InterministerialCommitteeonDrugs)competencesanditsincreased externalvisibilityaswellasthegeneralframeworksetbythenewnationaldrugsstrategy2010-2014on addictions(andnotexclusivelyonillicitsubstances’relatedproblems). The governmental programme 201415, foresees to further develop the national drugs action plan and specificallyreferstothedecentralisationofcareandharmreductionstructures,tothecreationofaheroin assisted treatment programme and to the extension of post–therapeutic offers. The 2010-2014 national drugactionplanwasexternallyevaluatedin2014(TrimbosInstituut–NL). Thenew2015-2019nationalactionplanondrugsandaddictionsbuildsupontheoutcomeofthereferred externalevaluationofthenationaldrugstrategyandactionplan2010-2014. GENERAL LEGAL FRAMEWORK16 Drug legislation and recent drug-related laws Thebasicnationaldruglaw,namely:‘Loiconcernantlaventedesubstancesmédicamenteusesetlalutte contrelatoxicomanie17’regulatesboth,thesellingofcontrolledmedicamentsandthefightagainstdrug addictionanddatesbacktothe19February1973.Ithasbeenlastamendedbythelawof27April200118. Besidesthedecriminalisationofcannabisuse,alleviationofpenaltiesforsimpledruguse,andanenhanced overall differentiation of penalties according to the type of drug offences and the nature of controlled substancesinvolved,thelawof27April2001foreseesalegalframeworkforaseriesoftreatmentandharm reduction measures, namely, drug substitution treatment, needle exchange and shooting galleries (state accreditedand,inadditiontoarticle13oftheGrandducaldecreeof30January2002(seebelow),Heroin AssistedTreatment(HAT). In2014,newlawswerevotedandadopted,mainlyrelatingtothegrand-ducaldecreesfrom1973and1974. 15 Gov.Declarationof2014,https://www.gouvernement.lu/3322796/Programme-gouvernemental.pdf 16 Legaltextsprevailonselectivelyproducedsummaries.Theintegralnationallegislationondrugsanddrugaddictionisavailableunder: http://www.emcdda.europa.eu/eldd 17 OfficialgazetteA1973,p.319 18 OfficialgazetteA2001,p.1180(Adoption:27/04/2001,Entryinforce:17/05/2001) 25 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Since June 10th 201419, custom officers were attributed new competences and are held to attend a professional training on the search and verification of drug law offences and controlled psychoactive substances.Moreover,anewdruglawoffencewasaddedtothelawfrom1973,namelyanyattemptto falsifybloodsamplesandmedicalprotocolsintheframeworkofdrug-tests. Grand Ducal Decrees Asregardsregulationmechanismsonthecontrolofsubstancesandprecursors,thenationaldruglegislation mainlyreliesonthefollowingGrandducaldecrees,amended(textorannexes)accordingtodecisionsonnew substances’inscriptionintonationallaw: - Grandducaldecreeof 4 March 1974regardingcertaintoxicsubstances Grandducaldecreeof20 March 1974regardingcertainpsychotropicsubstances Grandducaldecreeof26 March 1974establishingthelistofcontrollednarcotics Grandducaldecreeof8 May 1993regardingcommerceofnarcoticsandpsychotropicsubstances Grandducaldecreeof6 February 1997regardingsubstanceslistedinschedulesIIIandIVofthe UNConventiononpsychotropicsubstancesof21February1971 - Grandducaldecreeof13 February 2007onthesurveillanceandcommerceofdrugprecursors20 Thefulltextofthecurrentbasicnationaldruglawaswellasrecentdecreescanbeaccessedthroughthe followingwebsites:http://www.legilux.public.luorhttp://eldd.emcdda.europa.eu. CHANGES IN 2012 : ThegrandducaldecreeofJuly21,201221putsthefollowingsubstancesandplants undernationalcontrol: - MDPV (3,4 méthylène-dioxy-pyrovalerone) - Salvia Divinorium (Salvinorine A) - Mytragyna Speciosa, Kratom (Mytragynine,7-Hydroxymitragynine )» Furthermore, it regulates the modalities for the incorporation of certain cannabinoids in recognized medicaments as well as the cultivation of certain cannabis varieties for agricultural, non-psychoactive purposes. 19 Official gazette A-97 du 10 juin 2014, Loi du 30 mai 2014 portant modification de la loi modifiée du 19 février 1973 concernantlaventedesubstancesmédicamenteusesetlaluttecontrelatoxicomanie,p.1488(Adoption:30.05.2014.Entryintoforce: 10.06.2014.) 20 OfficialgazetteA2007(Adoption:30/01/2004,Entryinforce:13/02/2004).SeealsoELDD. Règlementgrand-ducaldu30janvier2004modifiantlerèglementgrand-ducalmodifiédu2février1995relatifàlafabricationetà lamisesurlemarchédecertainessubstancesutiliséespourlafabricationillicitedestupéfiantsetdesubstancespsychotropes. 21 Règlementgrand-ducaldu21juillet2012modifiant: • lerèglementgrand-ducalmodifiédu19février1974portantexécutiondelaloidu19février1973surlaventedessubstances médicamenteusesetlaluttecontrelatoxicomanie; • l’annexedurèglementgrand-ducalmodifiédu4mars1974concernantcertainessubstancestoxiques; • l’annexedurèglementgrand-ducalmodifiédu20mars1974concernantcertainessubstancespsychotropes; • l’annexedurèglementgrand-ducalmodifiédu26mars1974établissantlalistedesstupéfiants OfficialgazetteA157,p.1888(Adoption:21.07.2012,Entryinforce:30.07.2012) 26 - MDMC(Methylone) 4-MA(Methylamphetamine) CHANGES IN 2014: ThegrandducaldecreeofJanuary24,201423putsthefollowingsubstancesunder nationalcontrol: 5-(2-aminopropyl)-indole(5-IT) 2015 CHANGES IN 2013: ThegrandducaldecreeofJanuary29,201322putsthefollowingsubstancesunder nationalcontrol: CHANGES IN 2015: The grand ducal decree of June 19, 201524 puts the following substances under nationalcontrol: 4-iodo-2,5-diméthoxy-N-(2-méthoxybenzyl)phénéthylamine(25I-NBOMe); 3,4-dichloro-N-[[1-diméthylamino)cyclohéxyl]méthyl]benzamide(AH-7921); 2-(3-méthoxyphényl)-2-(éthylamino)cyclohéxanone(Méthoxétamine). Laws implementation Legallyspeaking,policehasnodiscretionalpower:eachoffence,oncedisclosed,mustbereported.However, dependingonthecase,(e.g.firstoffenceforcannabisuse)itmayoccurthatnofurtheractionistaken.Once adruglawoffencecasehasbeenreportedtothePublicProsecutor,thelatterdecidesontheopportunity toprosecuteornot.Thelegalconceptof‘prosecutionopportunity’maybeapplied,whichimpliesacase-bycasedecision. Drug-relatedoffencesarecoveredbythelaw(concerningthesaleofmedicinalsubstancesandthefight againstdrugaddiction)of19February1973(hereinafterreferredtoas‘the1973law’)thatwasmodified bythelawof27April2001. Eventhoughthe1973lawdoesnotspecificallyprovideforalternativemeasurestoprisonfordrug-addicted lawoffenders,thefollowingoptionsexist. Inaccordancewitharticle23ofthe1973law,casesinvolvingpersonaluseofdrugs(individuallyorina group)and/orcasesinvolvingoffencesagainstarticle8ofthe1973lawaredroppediftheoffender,before theillegalusewasdisclosed,undertooktreatmentfordrugaddiction.Moreover,thepublicprosecutorcan offertheoffendertheoptionofvoluntarytreatmentofhis/heraddiction. Accordingtothetermsofarticle24ofthe1973law,whenpreliminarychargesarebroughtforpersonaluse ofdrugsandwhenitisestablishedthattheoffenderisthesubjectofmedicaltreatment,theinvestigative judgemayordertreatmentfordrugaddictionattherequestoftheprosecutorortheaccusedperson. 22 Règlementgrand-ducaldu29janvier2013modifiant: • lerèglementgrand-ducalmodifiédu19février1974portantexécutiondelaloidu19février1973surlaventedessubstances médicamenteusesetlaluttecontrelatoxicomanie; • l’annexedurèglementgrand-ducalmodifiédu4mars1974concernantcertainessubstancestoxiques; • l’annexedurèglementgrand-ducalmodifiédu20mars1974concernantcertainessubstancespsychotropes; • l’annexedurèglementgrand-ducalmodifiédu26mars1974établissantlalistedesstupéfiants (Adoption:29.01.2013.Entryinforce:01.02.2013) 23 Règlementgrand-ducaldu24janvier2014modifiant: l’annexedurèglementgrand-ducalmodifiédu20mars1974concernantcertainessubstancespsychotropes; (Adoption:24.01.2014.Entryinforce:30.01.2014) 24 Règlementgrand-ducaldu19juin2015modifiant: l’annexedurèglementgrand-ducalmodifiédu20mars1974concernantcertainessubstancespsychotropes; (Adoption:19.06.2015.Entryinforce:17.07.2015) 27 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Article25ofthe1973lawmakesprovisionforthejuvenilecourttoreferanaddictedminortotreatment. Article26ofthe1973lawprovidesforthecourtstoorderadrugaddicttoundergotreatment,inwhichcase theverdictcanbepostponed.Iftheaccusedpersonmeetsallconditionsimposedbythecourts,thecharges forillegalusemaybedropped. Theabovemeasuresareonlyavailabletodrugusersandnoothercategoriesofoffenders. In addition to the special measures set forth in the 1973 law, the courts can still avail of the reformed sentencingmeasuresorofanyoftheextenuatingcircumstanceswhichareanoptionforalloffences,as outlinedintheCodeofCriminalLawandtheCodeofCriminalInvestigation.Theextenuatingcircumstances outlinedinArticles73to79oftheCodeofCriminalLawallowthejudgetheoptionoforderingcommunity serviceorafine,oreventoforgosentencinginfavourofapolicefine(betweenEUR25and248). Articles619to634(1)oftheCodeofCriminalInvestigationallowthejudgetheoptionofeitherpostponing theverdict,with/withoutatrialperiod,orsuspendingthesentence,with/withoutprobationandwitha trialperiod. Thelawof27April200125modifyingthebasicdruglawof19February1973bydecriminalisingcannabis use(withoutaggravatingcircumstances),andenhancingthedifferentiationofpenaltiesaccordingtothe typeofdrugoffencesandthenatureofcontrolledsubstancesinvolvedandthegrandducaldecreeof30 January200226onsubstitutiontreatment,havelargelycontributedtoincreasethecongruitybetweendrug legislations and prosecution routines. Also, current drug legislation and prosecution policies put higher priorityondrugdealingandtraffickingthanondrugconsumptionandpromoteharmandriskreduction measures.Thecreationofanationalsuperviseddrugconsumptionroomin2005isasoundexampleofthis holisticapproach. Asalegalprinciple,thereactiontoanoffencecommittedbyadrugusermustbeproportionaltotheharm itaimstoprevent.Infact,aslongasadrugaddictedpersonremainsasimpleuser,anydamagecaused tohimself/herselfandthelegalresponseremainsminimalaslongaspublicorderisnotgreatlydisturbed. However,ifthedrugusercausesharmtoothers,theresponsewillbecomefirmeraccordingtotheseriousness oftheoffence. NATIONAL ACTION PLAN, STRATEGY, EVALUATION AND COORDINATION Coordination mechanisms The coordination of drug demand reduction, risk reduction and related research is a competence of the MinistryofHealth.Since2000aNationalDrugCoordinator,appointedbytheMinisterofHealth,hasbeen mandatedwiththeoverallcoordination(includinginterministerialcoordination)inthedomainsofdrugrelateddemandandharmreductionandrepresentsLuxembourgattheinternationallevel.Supplyreduction andinternationalcooperationaspectsremainacompetenceoftheMinistryofJusticeandtheMinistryof ForeignAffairsrespectively. 25 OfficialgazetteA2001,p.1180(Adoption:27/04/2001,Entryinforce:17/05/2001)SeealsoELDD 26 OfficialgazetteA2002,p.232(Adoption:30/01/2002,Entryinforce:12/02/2002)SeealsoELDD 28 TheNationalDrugCoordinatorisalsotheheadofthenationaldelegationwithintheHorizontalWorking PartyonDrugs(EUCouncil)andthenationalPermanentCorrespondentwithinthePompidouGroup(Council ofEurope).Furthermore,hehasbeennominatedchairofthenationalsubstitutiontreatmentsurveillance commissionin2010andismemberofthenationalHIV/AIDSsurveillancecommission. 2015 Atthenationallevel,thecoordinationamongthecompetentministriestakesplaceintheInter-ministerial Commission on Drugs (ICD),chairedbytheNationalDrugsCoordinator.TheICDiscomposedofofficial delegatesfrominvolvedgovernmentaldepartmentsandconstitutesthetopadvisorylevelwithrespectto coordinationandorientationofactions.Both,theICDandtheMinistryofHealthareresponsibleforthe implementationofnationaldrugsstrategiesandactionplans.TheICD,hasanadvisoryroleandaddresses issuesrangingfromillicitdruguseand“legalhighs”toalcoholuseandprescriptiondrugsunderthegeneral headingofaddictivebehaviouranditsconsequences. National plan and strategy HavingtakenintoconsiderationtheEUdrugsstrategy2005-2012,theEUdrugsactionplan2009-2012,the nationalstrategyanddrugsactionplanaremeanttocontributetoahighlevelofhealthprotection,public securityandsocialcohesionandrelyontwopolicypillars,namelysupplyreductionanddemandreduction. Moreprecisely,itisdesignedtocontributetoreduceinitiationofdruguse,todevelopandmaintaindiversity andqualityincareandtreatmentoffers,totangiblyreducedruguseprevalenceinthegeneralpopulation aswellashealthandsocialdamagegeneratedbyillicitdruguseanddrugtrafficking. Thenew2015-2019nationalstrategyandactionplanondrugsandaddictionsbuildupontheoutcomeof thereferredexternalevaluationofthenationaldrugstrategyandactionplan2010-2014andwillbefurther adressedintheupcomingeditionofthisreport. Thenationalstrategyanddrugsactionplanaremeanttocontributetoahighlevelofhealthprotection, public security and social cohesion and rely on two policy pillars, namely supply reduction and demand reduction. More precisely, it is designed to contribute to reduce initiation of drug use, to develop and maintaindiversityandqualityincareandtreatmentoffers,totangiblyreducedruguseprevalenceinthe generalpopulationaswellashealthandsocialdamagegeneratedbyillicitdruguseanddrugtrafficking. Furthermore, the 2010-2014 national action plan27 included, in addition to international cooperation and research, information, evaluation (retained by the EU action plan), two more cross-cutting themes: coordinationandharm,riskandnuisancereduction.Luxembourgconsidersthelattertwoactivityfieldsto beessentialandoftransversalnature. The2010-2014governmentaldrugsstrategybuildeduponamoreholisticapproachthanthepreviousones. It addressed addictive behaviour as a whole and not only illicit drugs and drug addiction. Thus alcohol, tobaccoandpsychotropicpharmaceuticsdependenceaswellasaddictivebehaviournotassociatedwith substanceusearenowanintegralpartofanuniquestrategy.Specificactionplanshavebeenconceivedor arecurrentlyunderpreparationinordertointegratetheframeworkofaglobalnationalpolicyonaddictions. 27 MinistèredelaSanté(2010).Stratégieetpland’actiongouvernementaux2010-2014enmatièredeluttecontrelesdroguesetles addictions.MinistèredelaSanté.Luxembourg.Availableat:http://www.ms.public.lu/fr/activites/medecine-sociale-toxicomanie/ index.html 29 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Operationalobjectivesareasfollows: 1. Tocontributetothemaintenanceofindividualandcollectivewell-being. 2. To increase means for action and to improve coordination mechanisms and synergies between availableresourcesinordertoguaranteetheirbestpossibleuse. 3. Reducetheburdenforthecommunitybypromotingarationalcultureofinvestments,allowingto generatingsustainableachievements. 4. Toadequatelyupdatedrug-relatedlegislationandotherregulatoryinstrumentsaccordingtoemerging evidenceondrugsanddrugusepatternaswellasoncommercialstrategiesthatarebuildingupon newopportunitiescreatedbynewconsumertrends. 5. Toincreasetheknowledgebaseondrugsandaddictivebehaviourbypromotingresearchandthe broadestpossiblediffusionofobjectiveinformationtothegeneralpublicandspecifictargetgroups. 6. Toconsolidatemechanismsthatallowtocriticallyanalyseactionsandachievements,andbydoingso, improvedrugpolicymaking,actionplanningandimplementation. Thenationalplanlists60 separate actionsassociatedtoacleardefinitionoftasks,involvedmanagementactors,financialrequirements,deadlinesandperformanceindicators.Someofthereferredactionsare submittedtoaseriesofconditionstofulfilbytheactionmanagerinordertobeproposedforfinancing. The action plan reflects priorities set by the government: primary prevention (4 projects), treatment and care(7),socio-professionalreintegration(5),reductionofrisksanddamages(9),research,evaluationand information(8),supplyreduction(18),coordinationandinternationalrelations(9).Specialfocusisplaced onprimaryprevention,offersofaccommodationandhousing,socio-professionalreinsertionmeasures,diversificationandaccesstotherapeuticoffersandqualitymanagement. Theselectionofspecificactions,projectsorprogrammeshasoccurredonbasisofa6criteriamatrixincluding:pertinence,opportunity,feasibility,cost–benefice/qualityfactors,qualityassurancemechanismsand measurabilityofresultsorimpact. Implementation of policies and strategies Theoutcomeofanationaldrugsactionplanhighlyreliesonthewayithasbeenelaborated.Thesuccessive actionplansreflectthegeneralstrategyoftheMinistryofHealthinordertooptimizetheoverallinterventions inthefightagainstdrugsanddrugaddictioninthelightofstatedpriorities,assessedneedsandavailable resources. It constitutes an open framework meaning that complementary projects can be included if required. In2009,inordertobestmeetcurrentneedsintheelaborationofthe2010-2014actionplan,thenational drugcoordinatorhaslaunchedathirdmultilateralconsultationprocessinvolvingministerialdepartments, specialisedNGOsandcivilsociety.Aspecialworkinggroup,chairedbytheMinistryofHealth,performed a needs assessment and elaborated national recommendations focusing on specialised drug care and rehabilitationoffers.AmorerestrictedgroupcomposedofrepresentativesoftheMinistryofHealthand theNationalAddictionPreventionCentredraftedtheactionplanintheframeworkofprimaryprevention strategies. The priorities set by the Ministry of Health were discussed and, if necessary, complementary measureswereadded.Aconsensusonpriorityrankingsoflistedactionshasbeenreachedamonginvolved parties.Finally,allretainedactionswerestructuredinanoutputorientedwayasfollows: 30 TheactiveinvolvementofspecialisedNGOs/civilsocietyfromtheverystartoftheconceptualisationwork andconsensusmakingpriortotheimplementationphasehaveshowntobeamajorcriteriontoguarantee an effective implementation process. Summarily, one should stress that the multilateral involvement of competentactorsandthefactthatmostagenciesinvolvedintheimplementationprocessarefinancedand controlledbythecentrallycoordinatingMinistryofHealthhighlypromotetheeffectivenessofthenational strategicmodel. 2015 1.Description/objectiveofaction. 2.Responsibilities. 3.Budget. 4.Outcome. 5.Deadlinesforoutcomeandevaluation. Evaluation of policies and strategies Theimplementationprogressofthedrugsactionplanhasbeenonthepoliticalagendasinceitsstartin 2000 and consequently the visibility of achievements was continuously high. Media also contributed to thisenhancedawarenessandactivityboosting,especiallysincetheyhavebeenabletoidentifyacentral personalised key actor in the person of the national drug coordinator. Another positive side effect of consecutivedrugsactionplansisanincreasedcommitmentofNGOs/civilsocietyinthedrugpoliciesas theyareinvolvedfromtheverybeginningoftheprocess.Thegeneralpublichasequallywelcomedthedrug actionplanssinceitenablesthemtofollowuppubliceffortstofightaproblemofgreatconcernandto compareannouncedobjectiveswithachievedactions. Besideeffortsmadebyallinvolvedactorsandnetworks,thepositiveoutcomehasalsotoberelatedtothe considerableincreaseofthebudgetarymeansallocatedtothefightagainstdrugaddiction.Anincrease ofmorethan430%ofthebudgetinvestedbytheMinistryofHealthindrugdemandreductionoccurred between2000and2014. Budgetarymeansinvestedallowedtoincreaseresourcesintermsofprimaryprevention,toextendadmission capacitiesoflow-thresholdservices,toincreasethenumberofpost-therapeuticoffers,tofurtherregionalize ambulatory treatment offers, to improve technical control measures related to substitution treatment, to reducerisksanddamages,especiallyrelatedtosyntheticdrugsandthetransmissionofcertaininfectious diseases,endemictothepopulationofPDU,toreducetherateofdrugoverdosesandfinallytopromote researchactivitiesinthefield. Overthelast10yearstheconceptofimplementationfollow-up,evaluationandexternalevaluationstrategies havegainedinimportanceinthefieldofdrugsanddrugaddiction.Inthebeginningof2010,theMinister ofHealthjointlywiththeNationalDrugCoordinatorhaspresentedthenewdrugstrategyandactionplan 2010–2014.Thereferredactionplanisbasedontheevaluationoutcomeofpreviousactionplansand theassessmentofcurrentandfutureneeds.Inthiscontextandforthefirsttimenationally,afinalexternal outputandprogressevaluationofthenationaldrugstrategyandactionplan2005-2009asbeenperformed (TrimbosInstituut)28in2009. In2014,thedrugsstrategyandactionplan2010-2014werealsoevaluatedbytheTrimbosInstituut(Trautmann &Braam,2014).Thecontractualscopeoftheevaluationwasacriticalanalysisoftheimplementationofthe NationalDrugActionPlan2010-2014.Theaimwastoservepolicyrelevantinformationtothestakeholders involvedinmakingandimplementingdrugpolicyinLuxembourg.Thefollowingquestionswereaddressed: 28 TrimbosInstituut(2009).Evaluationofthenationaldrugactionplan(2005-2009)ofLuxembourg,Utrecht 31 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 •Priorities: Does the Action Plan address in an appropriate way the priorities put forward by the differentstakeholders,e.g.byclearproblemdefinitionsandclearlydefinedactions? •Conditions: WereconditionsgiventorealisetheactionsformulatedintheActionPlan,e.g.byserving the necessary instruments and resources, and by dividing and defining the responsibilities and by facilitating cooperation between the different stakeholders? Has the existing coordination structure provedtobeappropriateandefficient? •Results: Did the implementation of the National Drug Action Plan result in the realisation of the envisagedactions? •Process:Didtheprocessofpolicyformulationandimplementationgowell(managedappropriately, allowingandtaking-upinputfromallstakeholders,etc.)? Inimplementingtheevaluation,thefollowingguidingprincipleswereapplied: •Theevaluationisbasedonreliableandverifiablefacts/results; •Theevaluationprocessistransparenttoallstakeholders; •Allrelevantpartiesareinvitedtoparticipateintheevaluationprocess; •Allthesepartiesmustfeelfreetoexpresstheiropinions; •Theevaluationismeanttoformulateconcreterecommendationsthatcouldleadtoimprovementofthe quality,efficacyandefficiencyoftheLuxembourgdrugpolicy; •TheevaluationdoesnottakeastandinthepoliticaldebateinLuxembourg. The evaluation report also lists a set of recommendations regarding the new National Drug Action Plan 2015-2019, the coordination structure and the policy-making process. Evaluation results and recommendationsoftheworkinggroups,andthefinaloutputoftheexternalevaluationexercisehavebeen servingtheNationalDrugCoordinatorandtheInterministerialCommissiononDrugstoelaboratethenew nationaldrugsactionplan2015-2019. Other drug policy developments: Initiatives in Parliament and civil society Noprojectsorpropositionsoflawinrelationwithdrugsordrugaddictionwereintroducedin2014andno specificParliamentarydebatesorinitiativesinthefieldofillicitdrugsaretobereported. AselectionoftopicsaddressedbytheInterministerialGrouponDrugs(GIT29): - druguseinyoungsters; - substitutiontreatmentanddiacetylmorphineassistedtreatment; - superviseddruginjectionroomsinLuxembourgCityandinEsch/Alzette; - thephenomenonofresearchordesignerdrugsandtheirdiversion.Creationofnewlegalinstruments to fight the phenomenon of “legal highs”. Regulation of selling and confiscation of psychoactive substancesnotyetcontrolled; - NPStestingfacilities; - thespreadofshishasmoking. 29 GITisanabbreviationfor“GroupeInterministerielToxicomanies”,andreferstoainterministerialgroupondrugaddictionchairedby theNationalDrugCoordinator. 32 ECONOMIC ANALYSIS30 The fight against drugs is multidisciplinary. Thus, in Luxembourg 11 ministries and 13 departments are involvedtoadifferentextentintheenforcementofnationaldrugpolicies.AsinmostEUMemberstates, thestructureofthenationalstatebudgetdoesnotallowforadrugbudgetallocationanalysisexclusively basedonlabelledexpenditures.Followingaresomeofthepreliminaryproblemsonetypicallyisconfronted withinapublicexpenditurestudy: 2015 Public expenditures - Budgetlinesmaybegeneric(legal&illegaldrugs),aggregated(addictionprevention),overinclusive (socialsolidarity)orunidentifiable(others), - Apportionmentofbudgetsmaynotbeprovided, - Differencebetweenprovisionalbudget,votedbudgetandfinalexpenditure(provisionalbudgetoften moredetailedthanvotedbudget), - Expendituresmaybeannual,multiannual,unique,ordinary,extraordinary,etc.Iftheyoccurduringthe studyreferenceyear,theyshouldbeincludedeventhoughtheymightgiveabiasedpictureofaverage orroutineexpenditures,especiallywhentheyareimportant(e.g.investmentsinrealestate)31, - Intermsoffollow-up:budgetlinesmayberestructured,integratedordividedovertime, - In the field of public health, expenditures may result from direct state financing or social security reimbursement, - Lackofclarityduetonationalmixed(Multi-ministries)financing(e.g.PublicresearchCentres–multi projects’financing)orNational&EU&Internationalsharedfinancing, - Eligibilityofcooperationprojectsvs.variabilityofyearlycontributions, - Assessmentofimpactofgeneraleducationandeducationalinterventions(e.g.)onDDRimpossible. Thislistisnotexhaustive.Neverthelessdrug-relatedpublicexpenditurestudiesarefeasiblealthoughthey demandaconsiderableamountofanalyticalworkforlabelledordedicatedbudgetlinesastheyrequirea certaindegreeofcreativityasfarasnon-labelledexpendituresareconcerned.Researchersmaybeforced totakedecisionswhethertoincludeornotaseriesofexpenditures.Itisimportantthatthosedecisionsare taken according to reproducible standards and, even better so, according to harmonized and ultimately widelyrecognizedmethodologicalbenchmarks. Inordertotailorandfinetuneamethodologythatfitsthenationalcontextandwhichisinlinewiththe workplanoftheEMCDDA,anationalstudyondirecteconomiccostsofdrugpoliciesandinterventions has been performed from 1999 to 2002 and refers to data from 1999 (Origer 2002 b). (Etude du coût économique direct des interventions et de la politique publique en matière de drogues et de toxicomanies). Theoriginalresearchreportcanbeaccessedunder:http://www.relis.lu.Intheframeworkof2006EMCDDA contractualrequirements,anupdateoftheOriger2002studyhasbeenperformed.Adetaileddescriptionof themethodologyappliedin2002canbeconsultedintheoriginalstudy.Thesamemethodologyhasbeen appliedforthepresentandotheryearlyupdates. 30 SeerelatedchapterinPartB 31 Inordertohighlightthedifferentstatus/natureofbudgetlines,thefollowingabbreviationshavebeenusedintheexpendituretables: S.:Standardbudget(annualexpenditure/budgetline)I:Investments(uniqueyeardependantexpenditure) 33 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Methodology Inthe2015editionofthepresentreportanoverallestimationofdirectpublicexpendituresbasedonstudies performedrespectivelyin1999and2009arereported(Origer2002b,2010).Mainresultsoftheseformer comparative studies are summarised in tables 1.3 and 1.4. To date they represent the only overall drug relatedpublicexpendituresstudiesatthenationallevel.Asamatteroffact,exhaustivepublicexpenditure studiesarehighlytimeandcost-consumingexercisesandcanthereforenotbeperformedroutinely.This said,trendssurveillanceofdedicatedpublicbudgetsmayrelytransitionallyonpartialindicatorssuchas directpublichealthexpendituresforthefightagainstdrugsanddrugaddiction(drug-relatedprevention andtreatmentcosts). Theconstituentconceptsaredefinedasfollows: DIRECT:Excluding‘costsofindirectconsequences’(e.g.lossofincome,taxes)and‘nonquantifiablecosts’ (e.g.lossofwelfare)aswellasexpendituresrelatedtotheacquisitionofillicitdrugsbytheconsumerhimself. ECONOMIC: Monetary impact and not social impact (costs) or loss of life quality e.g. COSTS: Expendituresandnotrevenuescreatedbyillegaldrugmarket. NATIONAL DRUG POLICIES: Public finances and not private expenditures or investments. DRUG-RELATED TREATMENT: ‘... any activity that directly targets individuals who have problems with their drug use and which aims to improve the psychological, medical or social state of those who seek help for their drug problems. This activity often takes place at specialised facilities for drug users, but may also occur in the context of/in general services offering medical and/or psychological help to people with drug problems’(EMCDDA,2000).Theharmreductionapproachdirectlytargetsdrugaddictedpersonsandaims toimprovetheirpsychological,healthandsocialstateorsituation.Inthenationalunderstanding,drugrelatedtreatmentthereforealsoincludesharmreductioninterventions. Theappliedmethodologyreferstotheconceptsofthe‘Cost of Illness’(C.O.I.)theoryinoppositionto“CostBenefit”approach.COFOG and REUTERSclassificationswereappliedasrecommendedbytheEMCDDA. Thefollowingtechniqueshavebeenappliedandcombinedaccordingtoexistingcontexts: - - - - - - 34 Analysisofstatebudgetandprovisionalstatebudget Clarificationmeetingwithinvolvedfinancialauthorities Qualitativeinterviews AnalysisofactivityreportsofministerialdepartmentsandNGOs AnalysisofstateconventionsandfinancialstatementsofspecializedNGOs Detailedfinancialbreakdownandbudgetapportionmentprovidedondemandbyaseriesof institutions(NGOs,SocialSecurity,Hospitals) - Lawsandprojectsoflawregardingthebudgetofrevenuesandexpendituresofstate - Annualministerialactivityreports - Activityreportsofspecialisedagencies - StateconventionswithNGOs - AnnualfinancialstatementsofspecialisedNGOs - StatisticaloutputsandfinancialbreakdownsoftheCNS Main reference documents: 2015 Main data sources: Ministère des Finances (2011).Projetdeloiconcernantlebudgetdesrecettesetdesdépensesdel’Etat. MinistèredesFinances,Luxembourg. Ministère de la Santé (2012).Rapportd’activités2011,MinistèredelaSanté,Luxembourg. Ministère de la Santé (2005). Stratégieetpland’actionnationalenmatièredeluttecontrelesdrogues etlestoxicomanies2005–2009.MinistèredelaSanté.Luxembourg. Ministère de la Santé (2009). Stratégieetpland’actionnationalenmatièredeluttecontrelesdrogues etlesdépendances2010–2014.MinistèredelaSanté.Luxembourg. Origer, A. (2002b).Etudeducoûtéconomiquedirectdesinterventionsetdelapolitiquepubliqueen matièrededroguesetdetoxicomanies.Sériesderecherchen°4,PointfocalOEDTLuxembourg–CRP-Santé, Luxembourg. Origer, A. (2010).Updateofdirecteconomiccostsofnationaldrugpoliciesin2009.NationalReporton thestateofthedrugsproblemintheGrandDuchyofLuxembourg.PointfocalOEDTLuxembourg–CRPSanté,Luxembourg. Ministère de la Santé, Direction de la Santé & Cellule De Coordination « Drogues ». (2015). Stratégieetpland’actiongouvernementaux2015–2019enmatièredeluttecontrelesdroguesd’acquisition illiciteetlesaddictionsassociées.Luxembourg:MinistèredelaSanté. National estimates of labelled and non-labelled public drug demand reduction expenditures (2012) Table1.1providesansynopsisoflabelledandnon-labelleddrug-relatedpublicexpendituresinthefieldof drugprevention,treatmentandharmreduction. Table 1.1: Comparative analysis of drug demand reduction costs in Luxembourg 1999 vs. 2009/2012(EUR) 1999 Year Total expenditure 2009 2012 6,903,203.- 15,458,853.- 16,231,609.- 16.- 31.- 30,1.- 2,937.- 7,468.- 7,841.- Percentage of GNP 0.03 0.04 0.04 Percentage of state budget 0.15 0.17 0.15 Expenditure per inhabitant per year Expenditure per PDU Source: Origer2002,PFOEDT,REITOXreport2009/2012 35 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition National estimates of overall public drug-related expenditures (2009) (Origer 2010) Table 1.2: Overall expenditure in fiscal year 2009 by 1st level COFOG functions Labelled expenditures COFOG 1st level function Non-labelled expenditures TOTAL 1 General public services 122,000.- 59,100.- 181,100.- (0.4%) 3 Public Order and Safety 4,838,543.- 17,057,430.- 21,895,973.- (57%) 627,430.- 0.- 627,430.- (1.52%) 7,968,789.- 7,750,146.- 15,718,935.- (41%) 8 Recreation, culture and religion 0.- 2,000.- 2,000.- (0.01%) 9 Education 0.- 13,045.- 13,045.- (0.07%) 6 Housing and community amenities 7 Health TOTAL 38,438,483.- Table 1.3: Comparative analysis of drug related public expenditures treatment in Luxembourg 1999-2009 according to various indicators (EUR) 1999* Total expenditure 2009 23,345,000.- 38,438,483.- 54.- 77.- 9,934.- 15,562.- 0.13 0.1 0.5 0.4 Expenditure per inhabitant Expenditure per PDU Percentage of GNP Percentage of state budget Source: *Origer2002/2009 Budget TheNFPfollowsuptheannualbudgetaryevolutionbymeansofthemostaccessibleandspecificindicator, whichistheannualbudgetoftheMinistryofHealthallocatedtodrug-relatedactivities.Figure1.1shows thebudgetaryprogressionsincetheimplementationofthefirstdrugsactionplanin2000andfigure1.2 summarisestheannualprogressionofbudgetoftheMinistryofHealthandhumanresourcesallocatedto drug-relatedactivities. Table 1.4: Annual budget of the Ministry of Health allocated to drug demand reduction activities 2000–2014 Year Budget (EUR) Cumulative progression rate 2000 2005 2011 2012 2013 2014 2,066,000.- 6,196,000.- 8,321,620.- 8,590,033.- 9,531,000.- 10,949,211- Reference year 200% 303% 316% 360% 430% Source: Projetdeloiconcernantlebudgetdesrecettesetdesdépensesdel’Etatpourl’exercice2010.Volume1. (MinistèredesFinances1999-2014) 36 Table 1.5: Annual progression of the budget of the Ministry of Health and human resources allocated to drugrelated activities 2004 – 2014 Annualprogressionrate Annualcumulative progressionrate Dedicatedhuman resources FullTimeEquivalent (FTE) 2004 2006 2009 2011 2012 2013 2014 5,771,000.- 6,584,000.- 7,991,583.- 8,321,620.- 8,590,033.- 9,531,000.- 10,949,211.Reference 6.27% 9.65% 4.13% 3.23% 10.9% 14.8% year Reference 14.09% 38.48% 44.20% 48.85% 65.15% 89.73% year 59.5 69.25 83.75 88.75 90.50 100.50 114.75 Annualprogressionrate Annualcumulative progressionrate Reference year Reference year 9.06% 6.70% 1.7% 2.25% 11.05% 3.61% 16.39% 40.76% 49.16% 52.52% 68.91% 92.85% 2015 Budget Year Budget (EUR) Source: Projetdeloiconcernantlebudgetdesrecettesetdesdépensesdel’Etatpourl’exercice2006/2010.Volume1. (MinistèredesFinances2004-2014) Funding arrangements Fundingofdrug-relatedinterventionsiscentralisedatstatelevel.Thereexistnospecificregionalorlocal fundingmechanisms.Fewdrugpreventionactivitiesaresubsidisedbycouncildistrictsonanadhocbasis. Respective ministries or governmental departments, according to their attributions, are coordinating the creation, the implementation and the funding of required infrastructures. Governmental departments directlyrelyonthestatebudgetwhileNGOsinvolvedindrugtreatmentorresearchactivitieshaveeither signedaso-called‘convention de collaboration’withconcernedministriesorarefinancedorco-financed onbasisofregularsubventions.Agovernmentaldelegatefollows-upactivitiesandfunctioningofagiven NGObyattendingamandatory‘coordinationplatform’. The funding of the drug action plan is subject to an annual budgetary decisions’ process. Specific local projectsdesignedbynon-governmentalactorsrequiringexternalfinancialsupportaregenerallysubmitted torespectiveministriesortoothernationalfundingsources(FundAgainstDrugTrafficking,Foundations, privatefunds,etc.)orinternationalbodies(EU,EMCDDA,etc.). Social costs Origer(2002)assessedthe direct economic costs of policies and interventions in the field of illicit drug usereferredtoyear1999(seewww.relis.lu).AnupdateoftheOriger2002studyhasbeenperformed accordingtodatafor2007andresultshavebeenpresentedinthe2008editionofthenationalreport. In 2006 and 2014, the STATEC (Central service of statistics and economical studies) published studies estimating the economic impact of the illegal drugs related activities in Luxembourg(Statec, 2006,2014).ThesestudieswerecarriedoutwithintheframeworkofaEuropeanprojectintendedtoimprove thecomparabilityandthecoverageofnationalaccounting.Resultswerepresentedinthe2009editionof thenationalreport.Resultsofthe2014studymayberetrievedfrom: http://www.statistiques.public.lu/catalogue-publications/regards/2014/PDF-13-2014.pdf 37 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 2. DRUG USE IN THE GENERAL POPULATION AND IN SPECIFIC TARGETED GROUPS INTRODUCTION Drugsreferredtointhepresentreportincludenarcoticdrugsandpsychotropicsubstancescoveredbythe internationaldrugcontrolconventions(theSingleConventiononNarcoticDrugsof1961,asamendedbythe 1972Protocol,theConventiononPsychotropicSubstancesof1971andtheConventionagainstIllicitTraffic inNarcoticDrugsandPsychotropicSubstancesof1988).DrugsnotlistedinthelatterUNconventionsare addressedbythepresentstrategyonlyinthecontextoftheirassociatedusetolisteddrugs. ‘Druguse’ishereinafterdefinedastheself-administrationofapsychoactivesubstance,that,wheningested, affects mental processes. Psychoactive substances may be of licit or illicit production, sale, or use and associatedrisksmaybeconsideredmoreorlessimportant. Prevalence estimations on drug use in the generalpopulationarebasedondatacollectedinmore(e.g. schools) orless(generalpopulation:agegroup 15-64years)targetedandrepresentativesamplesofthe nationaloverallpopulation.Accordingtothemostrecentsurveys,cannabisandderivatesarebyfarthe most common illicitly used psychoactive substances in the national population followed by cocaïne and Amphetamine Type Stimulants (ATS). Cannabis use in youngsters has been decreasing over the last 10 years but still shows the highest prevalence regardless age categories, whereas the prevalence of other psychoactivedrugsvariesaccordingtoageanddatacollectionsettingfactors.Mostrecentschoolsurvey datapresentedinthepresentreportstemfromtheHBSCstudy2010.Newprevalencedatawillbeprovided inthecourseof2016byarecentgeneralpopulationsurveyonhealthbehaviour(EuropeanHealthInterview Survey–EHIS). DRUG USE IN THE GENERAL POPULATION Todate,nonational,large-scale(representative)generalpopulationsurveyondrugusehasbeenconducted. Severalcommunityortargetedpopulationsurveys,however,allowestimatingcurrentprevalence.TheNFP managedtoagreewithmembersofthenationalepidemiologicalworkinggrouponhealthbehaviouron thenecessitytoincludeillicitdruguseinthenationalversionofEHIS(EuropeanHealthInterviewSurvey). AdataprotocolbasedonEMCDDArequirementshasbeenapprovedandtested.Specialattentionwasalso paidtonewpsychoactivesubstancesandrelatedquestionswereincludedintheEHISquestionnaire.First resultsoftheEHISsurveyshouldbeavailableinthecourseof2016. AprimarypreventionpilotprojectatcommunitylevelwaslaunchedbytheCePTin1995.In2000,13councildistrictsparticipatedinthisproject.Intheframeworkofthisprojectanon-representativesurveyondrug useinthegeneralpopulation(reference1:“Fischer1999study”)wasconducted. 38 Fischer U. CH. & Krieger W. (1999).SuchtpräventiounanderGemeng– Entwicklung,DurchführungundEvaluationeinesModellszurgemeindeorientierten Suchtprävention,CePT,Luxembourg. EN:Drugpreventionatthecommunallevel Year of data collection 1998 Single/repeated study Singlestudy Context DrugPrevention–PublicHealth–Crosssectional Area covered 7councildistrictsoftheGrand-DuchyofLuxembourg Age range 12-60years Data coll. Procedure Anonymousself-administratedquestionnaires Sample size 667validcases 2015 REFERENCE 1 Source: Fischer1999 Fig. 2.1 Lifetime prevalence according to age (valid %) (Fischer 1999) 20 15 10 5 0 12-16 years 17- 25 years 26 - 40 years 41 - 60 years Cannabis 4.5 18.9 15.6 1.4 Ecstasy 0.6 2.5 1.8 0 LSD 0.6 0.6 4.8 0 Cocaine 0 0.6 4.2 0 Heroin 0 0.6 2.4 0 AsecondsurveyconductedbytheCePTwaspublishedin2000(“Fischer2000study”).Eventhoughcannabis consumptionwasthemainsubjectofthestudy,severalothersubstanceshavebeentakenintoaccount.The sampleshavebeendrawnontheonehandfromacinemavisitor’spopulationinLuxembourgCity(ref.:2.1) andontheotherhandfromapopulationof6councildistricts(ref.:2.2). 39 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues REFERENCE 2.1 15 Fischer U. CH. (2000)CannabisinLuxemburg–EineAnalysederaktuellenSituation, CePT,Luxembourg.EN.:CannabisinLuxembourg Year of data collection 1999 Single/repeated study Singlestudy Context DrugPrevention–PublicHealth–Crosssectional Area covered CinemasinLuxembourg-City Age range 15-64years Data coll. Procedure On-siteinterviews Sample size 991validcases Sampling procedure Randomsamplingofcinemacustomers Remark DetailedresultsofbothsurveysareprovidedinEMCDDAstandardtables Fig. 2.2 Current and lifetime prevalence of cannabis use according to age: Cinema sample (valid %) (Fischer 2000) 45 40 35 30 25 20 15 10 5 0 10-16 years 17- 25 years 26 - 40 years Cannabis - lifetime prevalence 26.3 40.1 30.9 14.3 Cannabis - current use prevalence 17.6 23.3 11.2 7.9 REFERENCE 2.2 40 Edition 41 - 60 years Fischer U. CH. (2000) CannabisinLuxemburg–EineAnalysederaktuellenSituation, CePT,Luxembourg.EN.: CannabisinLuxembourg Year of data collection 1999 Single/repeated study Singlestudy Context DrugPrevention–PublicHealth–Crosssectional Area covered 6districtcouncils Age range 12to60years Data coll. Procedure Mailquestionnaire Sample size 486validcases Sampling procedure Randomsampling Response rate 27.7% Current and lifetime prevalence of cannabis use according to age Sample: Council districts (valid %) (Fischer 2000) 2015 Fig. 2.3 20 15 10 5 0 12 - 16 years 17 - 25 years 26 - 40 years 41 - 60 years Cannabis - lifetime prevalence 7.2 16.5 16.4 2.9 Cannabis - current use prevalence 3.2 5.8 3.9 0 Ascanbeseeninfigures2.2and2.3,cannabisprevalenceratesshowrelevantdifferencesaccordingtotype ofrecruitmentsettings. DRUG USE IN THE SCHOOL AND YOUTH POPULATION lIFetIMe PReVAleNCe: SChool PoPUlAtIoN REFERENCE 1 Matheis J. et al. (1995) ‘SchüleranDrogen’,IEES,Luxembourg. EN.: StudentsandDrugs Year of data collection 1992 Single/repeated study Repeatedstudy1983–92 Context PublicHealth Area covered Nationwide Type of school 5thyearsofalltypesofsecondaryschoolclassesatthenationallevel Age range 16-20years(AGEENTERING5THCLASS) Data coll. Procedure Anonymousself-administratedquestionnairesinschoolclasses Sample size 1,341 41 è Fig. 2.4 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Lifetime prevalence of drug use according to age (valid %) (Matheis, Prussen 1995) 35 30 25 20 15 10 5 0 up to16 years 17 years 18 years 19 years 20 years and more Cannabis 6 8 9.5 10.5 32.6 Stimulants 10.6 7.4 10.1 12.5 14.1 Solvents 2.6 2.4 3.7 3.8 10.8 LSD 0.9 1.5 2.9 3.1 3.2 Cocaine 0.9 0.4 1.4 1.3 5.4 Ecstasy 0.9 0.2 1.7 2.5 2.2 Heroin 0 0.2 1.4 1.3 4.3 REFERENCE 2 42 Meisch, P. (1998),LesdroguesdetypeecstasyauGrand-DuchédeLuxembourg,CePT, Luxembourg.EN: EcstasytypedrugsintheG.D.ofLuxembourg Year of data collection 1997 Single/repeated study Single Context PublicHealth–primarydrugprevention Area covered Nationwide Type of school 2ndand6thyearsofclassical(N:311)andtechnical(N:355)secondary schools Age range 13-22years(13-14:N347;15-17:N193;18-22:N118) Data coll. Procedure Self-administratedquestionnaires Sample size 666 Sampling frame Schoolsparticipatinginthe“European‘Health-Schools’network” Response rate (M, F, T) 100% Fig. 2.5 Lifetime prevalence of drug use according to age groups (valid %) (Meisch 1998) 2015 25 20 15 10 5 0 13-14 15-17 18-22 total Cannabis 7.2 18.6 22.9 13.5 Solvents 4.3 2 2.5 3.3 Cocaine 0.3 1 0.9 0.6 Ecstasy 1.5 1.6 4.2 2.1 Heroin 0.6 0.5 0 0.5 REFERENCE 3 Das Wohlbefinden der Jugend – HBSC Studie (1999 / 2006 / 2010), Ministèredel’EducationNationaledelaJeunesseetdesSports,DirectiondelaSanté, Luxembourg.EN.: HealthandHealthBehaviourinSchoolAgedChildren. Year of data collection 1999/2006/2010 Single/repeated study Repeatedstudy(intendedeach4years) Context HealthandHealthBehaviouramongYoungPeople–WHOcross-national study Area covered Nationwide,representative Type of school Secondaryschools Age range 12-18years Data coll. Procedure Anonymousself-administratedquestionnairesinschoolclasses Sample size 7,000–8,000 Response rate (M,F,T) Over95% 43 è Fig. 2.6 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Lifetime and last 12 months prevalence of any drug. Age 12-18 years (valid %) (HBSC 1999 - 2010) 40 35 30 25 20 15 10 5 0 1999 2006 2010 Any drug - Lifetime prevalence 27.64 20.34 19.59 Any drug - last 12 months prevalence 23.24 15.53 15.56 Lifetimeandlast12months’prevalenceratesofillicitdruguseinyoungsters,aged12to18years,have beenshowingaharshlydecreasingtrendbetween1999and2006andafairstabilisationtowards2010. Fig 2.7 Lifetime prevalence of illicit drug use acording to type of drugs. Total school population aged 12-18 years (valid %) (HBSC 1999 - 2010) 24.3 25 1999 2010 20 15.5 15 10 5 2.1 2.9 1 3.8 3.6 1.4 0.8 0.7 1.8 1.7 1 1.4 0.7 1.1 44 M us hr oo m s LS D /g lu e So lv en ts C oc ai ne O pi at es ST A ty pe XT C C an na bi s 0 Fig 2.8 Lifetime prevalence according to age and type of drugs (valid %) (HBSC 2010) 40 2015 35 30 25 20 15 10 5 0 Cannabis Fig 2.9 12 years 13 14 15 16 17 18 0.7 2.6 8.7 15.9 25.1 28.9 39.6 XTC type 0.2 0.3 0.4 1.3 1.5 1.5 2.7 STA 0.3 0.8 1.5 1.4 1.6 2.4 2.7 Opiates 0.1 0.5 0.7 1 1 0.9 0.6 Cocaine 0.6 0.7 0.9 2.5 2.4 2.5 3.2 Solvents / glue 0.2 0.6 1.1 1.7 1.4 0.5 1.3 LSD 0.2 0.1 0.2 1 0.9 1.2 1.5 Mushrooms 0.1 0.3 0.7 0.8 1.5 2.3 2.7 Lifetime prevalence according to age and type of drugs (valid %) (HBSC 1999) 45 40 35 30 25 20 15 10 5 0 12 ans 13 14 15 16 17 18 Cannabis 6.5 3.5 15.4 21.8 33.4 35.8 43.6 XTC type 1.5 1 2.3 1.1 2.6 3 3.2 STA 1.5 2.2 2.2 2.7 3.5 3.9 3.7 Opiates 0 0.3 1.1 0.7 1.2 1 1 Cocaine 1.5 0.8 2.2 1.5 1.6 2.3 2 Solvents/glue 3.6 2.8 3.8 3.8 3.6 3.3 4.2 LSD 0.4 0.3 1.7 1.3 1.7 1.5 2.7 Mushrooms 0.4 0.3 2.3 3.2 4.9 7 7.1 AcomparisonofserialHBSCdatafrom1999and2010revealshighestprevalenceratesofcannabisuse, irrespectively of age and year of survey. Lifetime cocaine use is the only to show a consistently higher prevalencein15to18yearsagedschoolchildrenin2010comparedto1999.Opiates’useinyoungstershas beenremainingconsistentlylowoverthesameperiod. 45 è Fig 2.10 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Longitudinal lifetime prevalence data according to type of drugs in age group 15-16 years. (valid %) 30 20 10 0 cannabis opiates cocaine amphet. ecstasy LSD mush. medic. solvents other HBSC 2010 20.5 1 2.5 1.5 1.4 0.9 1.1 1.9 1.5 3.6 HBSC 1999 27.7 0.8 1.5 3.1 1.8 1.4 4.1 2.8 3.6 2 6 0 0.9 0.9 0.9 Matheis 1992 Fig 2.11 2.6 Longitudinal lifetime prevalence data according to type of drugs in age group 13-14 years. (valid %) 12 9 6 3 0 cannabis opiates cocaine amphet. ecstasy LSD mush. medic. solvents HBSC 2010 5.6 0.6 0.8 1.1 0.3 0.2 0.5 0.6 0.9 1.5 HBSC 1999 10.5 0.8 1.6 2.3 1.7 1.1 1.6 1.5 3.3 1.6 2.4 1.9 2 2.3 1.4 0.6 Fischer 1999 9.7 1.6 2 Meisch 1997 7.2 0.6 0.3 other 4.3 The HBSC surveys (1999 / 2006 / 2010), the Fischer study (1999) and the serial surveys by Matheis (1985/95) provide trends in lifetime prevalence between 1992/1997 and 2010 applied to age groups 13-16.Comparedtotheendofthe20thcentury,mostrecentdatafromHBSCsurveysindicatedecreasing lifetimeprevalenceratesforallsubstanceswiththenotableexceptionofcocaineusein15to16yearsold studentswitnessingatangibleincrease. 46 lASt 12 MoNthS PReVAleNCe: SChool PoPUlAtIoN Last 12 months prevalence of illicit drug use according to type of drugs. Total school population aged 12-18 years (valid %) (HBSC 1999 - 2010) 2015 Fig 2.12 25 20.6 20 1999 15 12.1 2010 10 5 1.9 1.3 0.7 1.1 0.6 0.5 1.2 1.3 1.6 0.7 0.9 0.6 2.7 0.8 Fig 2.13 M us hr oo m s LS D /g lu e So lv en ts C oc ai ne O pi at es ST A XT C C an na bi ty pe s 0 Last 12 months prevalence according to age and type of drugs (valid %) (HBSC 2010) 25 20 15 10 5 0 Cannabis 12 years 13 14 15 16 17 18 1.1 2.3 7.8 13.2 20 22.4 24.8 1.6 XTC type 0 0.3 0.2 0.8 1.1 1.1 STA 0 0.6 1.4 1 1.1 2 2.1 Opiates 0 0.5 0.4 0.6 0.7 0.5 0.6 Cocaine 0 0.6 0.9 1.7 2 1.5 2.1 Solvents 0 0.2 0.8 1.3 1.1 0.5 0.8 0.6 0.1 0.3 0.8 0.9 1.1 1.2 0 0.1 0.7 0.7 1.4 1.1 2 LSD Mushrooms Latest12months’prevalencedata(HBSC2010)confirmhighestratesforcannabisusefollowedbystimulant typeamphetaminesandcocaineinschoolchildrenaged12to18years. 47 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Table 2.1: HBSC 2002 / 2006 / 2010 : Trend analysis according to age and type of drug (last 12 months prevalence) 13 HBSC /Year Cannabis 14 15 16 17 2002 2006 2010 2002 2006 2010 2002 2006 2010 2002 2006 2010 2002 2006 2010 3,5 3,0 2,3 15,4 7,9 8,0 21,8 18,3 13,2 33,4 18,8 20,3 35,8 23,9 22,5 XTC 1 0,6 0,3 2,3 0,8 0,2 1,1 1,5 0,8 2,6 1,1 1,1 3 1,4 1,1 STA 2,2 0,8 0,6 2,2 1,3 1,4 2,7 1,8 1,0 3,5 1,5 1,1 3,9 1,0 2,0 Opiates 0,3 0,3 0,5 1,1 0,9 0,4 0,7 1,3 0,6 1,2 0,8 0,7 1,0 0,5 0,5 Medic. 0,6 0,8 0,2 2,2 1,3 0,6 2,1 2,4 1,3 3,6 1,6 1,2 2,9 1,9 1,4 Cocaine 0,8 0,8 0,6 2,2 1,4 0,9 1,5 3,2 1,7 1,6 1,4 2,0 2,0 1,6 1,5 Glue/solvents 2,8 0,9 0,2 3,8 1,5 0,8 3,8 2 1,3 3,6 1,5 1,1 4,2 1,3 0,5 LSD 0,3 0,1 0,1 1,7 0,4 0,3 1,3 0,8 0,8 1,7 0,6 0,9 2,7 0,7 1,1 Mushrooms 0,3 0,5 0,1 2,3 0,8 0,7 3,2 2,1 0,7 4,9 1,8 1,4 7,1 2,1 1,1 - downward trend 2002 - 2010 - upward trend 2002 - 2010 SerialHBSCsurveys(2002,2006,2010)providelast12monthsnationalprevalencefiguresin12to18 (respectively13to17)yearsagedschoolchildren.Resultsmirrorrespectiveproportionsoflifetimeprevalence rateswithparticularemphasisonhighcannabisprevalenceinallagegroupsfollowedbyXTCtypeproducts andcocaine. Table2.1showsprevalencetrendsbetween2002and2010.Avastmajorityofsubstancesshowdeclining last12monthsprevalenceratesinallagegroups.Cocaineusein15to16yearsagedyoungsters,however, hasbeenshowinganotableincreaseduringthereferredobservationperiod. lASt 30 dAyS PReVAleNCe: SChool PoPUlAtIoN Fig 2.14 Last 30 days prevalence according to type of drugs: school population - 13-20 years (Fischer 2000) 15 10 5 0 Fischer (2000) 1999 data 48 Cannabis Heroin Cocaine Ecstasy LSD Psilocybin 13.8 0.6 1.3 1.1 1 1.8 Fischer U. CH.(2000),Cannabis–EineAnalysederaktuellenSituation,CePT, Luxembourg.EN.:Cannabis–Rapidassessmentofthecurrentnationalsituation. 2015 REFERENCE 4 Year of data collection 1999 Single/repeated study Single Context Cannabisprevalence Area covered Nationwide Type of school 2ndand6thyearsofsecondaryschools Age range 13-20years Data coll. Procedure Self-administratedquestionnaires Sample size 562 Sampling frame Schoolsselectedonbasisoftheirgeographicalsituation(national representativity),exhaustivestudentsamplingwithintheselectedschools. Response rate (M, F, T) 100% Fischer(1999)provideslast30daysprevalencefiguresfor13to20yearoldschoolchildren.Cannabisand ecstasyprevalencefigure13.8%and1.1%,respectively.Heroin,cocaineandLSDprevalenceratesareclose tolast12monthsprevalencerates.Genderbreakdownsarecurrentlynotavailable.HBSCsurveysdidnot includequestionsonlast30daysuseofdifferentdrugs,exceptforcannabis.Last30dayscannabisuseis addressedbelow. IN-dePth dAtA oN CANNABIS USe PReVAleNCe IN SChool-Aged ChIldReN32 Fig 2.15 Lifetime, last 12 months and last 30 days prevalence of cannabis use. Age 12-18 years (valid %) (HBSC 1999 - 2010) 30 25 20 15 10 5 0 1999 2006 2010 15.5 Cannabis - Lifetime 24.57 19.15 Cannabis - last 12 months 20.76 13.81 12 7.27 6.3 Cannabis - last 30 days 32 Discrepanciesbetweennationaldataof2010,presentedinthepresentreport,andtheinternationalHBSCreportdoexistandare mainlyduetodifferentproceduresinagecalculation,inincoherentanswers’managementandsupplementarydatanotyetavailable atthetimeofdatasubmissionfortheinternationalreport. 49 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Table 2.2 HBSC 2010: Cannabis prevalence rates according to age categories 11 – 15 years 11 years Male Female 13 years Total Male Female 15 years Total Male Female Total Cannabislifetime 0.8* 0.0 0.4 2.7 2.5 2.6 18.2* 13.6 15.9 Cannabis12month 1.0* 0.0 0.5 2.4 2.1 2.3 14.2 12.2 13.2 Cannabis30days 0.8* 0.0 0.4 1.6 1.1 1.3 7.7 6.5 7.1 *Significantgenderdifferenceatp<0.05 Fig 2.16 Lifetime prevalence of cannabis use according to gender. Age: 15 years. (HBSC 2002 - 2010) Male 30 Female Total 20 10 0 2002* 2006 2010* 18.21 Male 23.99 21.73 Female 18.76 19.38 13.4 Total 21.52 20.59 15.86 *Significantgenderdifferenceatp<0.05 Fig 2.17 Last 12 months prevalence of cannabis use according to gender. Age: 15 years. (HBSC 2002 - 2010) Male 30 Female Total 20 10 0 50 2002 2006 2010 21.84 19.18 14.24 17.27 15.65 12.2 17.45 13.24 Male Female Total 19.68 Last 30 days prevalence of cannabis use according to gender. Age: 15 years. (HBSC 2006 - 2010) Male 30 Female Total 2015 Fig 2.18 20 10 0 2006* Male 2010 11.91 7.67 Female 7.12 6.48 Total 9.56 7.09 *Significantgenderdifferenceatp<0.05 Fig 2.19 Last 30 days cannabis prevalence according to age (valid %) (HBSC 2010) 15 10 5 0 Cannabis use last 30 days 12 years 13 14 15 16 17 18 0.7 1.3 4.4 7.1 10.1 10.8 13.7 Lifetime,recentandcurrentcannabisuseprevalenceratesin15yearsoldyoungstershavebeendeclining remarkablyduringthefirstdecadeofthe21stcentury.Themostrelevantdifferencesaccordingtogender arelowercannabisprevalencefiguresforfemales.Thesedifferencesappeartobestatisticallysignificant (p<0.05)forlifetimeandlast30daysprevalencein2006andforlifetimeprevalencein2010. 51 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 DRUG USE AMONG TARGETED GROUPS In2007,theNationalEMCDDAfocalpointpublishedtheresultsofactionresearchonHIVandhepatitis infectionsindrugusers(OrigerandRemoville,2007). REFERENCE 5 Origer A., Removille N., (2007) Prévalence et propagation des hépatites virales A,B,C et du HIV au sein de la population problématique de drogues d’acquisition illicite, Point Focal OEDT / CRP-Santé. Luxembourg. EN: PrevalencestudyonHIV,HCV,HBVandHAVinPDUinLuxembourg Year 2007 Single/repeated study Single Context HIV,HCVandinjectingdruguseprevalencenationalPDUpopulation Area covered In-andoutpatientdrugagenciesandnationalprisons Type sample Randomsamplingduring8monthsin2005 Age range >17 Data coll. Procedure ANONYMOUSSELF-ADMINISTRATEDQUESTIONNAIRESAND SEROLOGICALTESTING Sample size 366 Sampling frame Randomsampling Response rate (M, F, T) 33.96% MAIN RESULTS: -67.21%ofPDUreportedatleast1prisonstayduringthelast10years -ofwhich56.1%reportdruguseinprison -ofwhich54.3%reportIDUinprison Furthermore, a study on “Drug addiction in the working environment: Prevalence of use of psychoactive substances use and its relationship to high-risk occupation and stress”(S.KripplerandF.Kittel,2011)33has beenpublishedinApril2011.Theaimofthestudywastoexploretheprevalenceoflicitandillicitpsychoactive substancesuseamongemployeesagedbetween18–39yearsintheprivatesectorintheG.D.ofLuxembourg aswellasitsrelationshiptohighriskoccupationsandotherpotentialriskfactorsinoccupationalsettings, (e.g.high-stresstasks).Forthispurpose,aself-administeredquestionnairecontainingvalidatedtoolsfrom theEMCDDAconcerningstreetdrugs,theAUDIT-CforalcoholuseandtheSiegristEffort-Reward-Imbalance questionnaire on stress were distributed during occupational medical check-ups during June and July 2008. Alcohol, cigarettes, amphetamines, cocaine, heroin, ecstasy, LSD and psychotropic drugs use were investigatedtogetherwithsocio-demographicandprofessionalfactors.Amongthe1358respondents,8.4% consumedillicitsubstances,cannabisaccountingfor8.2%.High-riskoccupationsaresignificantlyrelatedto illegalsubstanceuse.Age(young),gender(men),smokingandfamilysituation(bachelorlivingalone)show thesamerelationship.Noeffectwasfoundforstressonillicitdrugusewhiletherewasasignificanteffect onalcoholandprescriptiondruguseinbivariateanalysisonly. 33 KripplerS,KittelF.Toxicomaniesenmilieuprofessionnel:prévalencedel’usagedesubstancespsychoactivesetsarelationavecle postedesécuritéetlestress.Archivesdesmaladiesprofessionnellesetdel’environnement,2011,vol.72,n°2,pp.181-188 52 Q12. Have you used cannabis yourself? Yes–inpastyear Yes–butmore thanoneyearago No,Ihavenever used Don’twantto answer LU 7(7) 18(10) 69(77) 1(2) EU28(EU27) 10(8) 14(12) 69(72) 0(2) 2015 AnewFlashEurobarometerN°401(formoredetailsseechapter3)wascarriedoutinJune2014onthe requestoftheEuropeanCommissionamongyoungpeopleaged15-24.Twoitemsreferredtoself-reported useofcannabisandtotheexperiencewithlegalsubstancesthatimitatetheeffectsofillicitdrugs(“legal highs”). 3. In certain countries some new substances that imitate the effects of illicit drugs are being sold as legal substances in the form of – for example – powders, tablets/pills or herbs. Have you ever used such substances? No,Ihaveneverused Yes,Ihaveusedsuchsubstances LU 93(93) 7(7) EU28(EU27) 92(95) 8(5) Source: EurobarometerN°401(330) Concerningself-reporteduseofcannabis,thepercentageofyoungpeopleinLuxembourg(69%)reporting nothavingusedcannabisisequivalenttotheEuropeanaverage.Allinall,self-reportedlast12months cannabisuseamongLuxembourgyoungstersaverageappearstobestablecomparedtotheEurobarometer N°330in2011. 8%ofyoungpeopleinEuropereportedhavingused“legalhighs”–newsubstancesimitatingtheeffectsof illicitdrugs.Theself–reporteduseofrespondentsinLuxembourgfigures7%(stable). IntheframeworkoftheINTERREGIVAprojectMAG-Net,theCePTconductedananonymoussurveyamong partygoers on representative music events which took place in Luxembourg (Duscherer, K. & Paulos, C., 2013).In2012,4,413questionnaireswerecompleted,4,284validated,themedianageoftheparticipants was21years.Onequestiondirectlyaddressedparticipants’druguseduringthelasttwoweeks:ascanbe seeninFigure2.20,alcoholwasbyfarthemostfrequentpsychoactivesubstancedeclared(86.9%),followed bytobacco(51.1%)andcannabis(24.7%).Allotherdrugsrangedbelowthe5%mark,likeamphetamines, ecstasy,cocaine,LSD,magicmushrooms,ketamineorheroin. 53 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Fig 2.20 Use of psychoactive substances during the last two weeks by partygoers (valid %) (2012) 100 80 60 40 20 0 alcohol tobacco cannabis cocaine ampheta mines ecstasy LSD magic ketamin mushrooms heroin female 84.0 47.6 16.8 2.0 1.1 1.0 1.0 1.1 0.4 0.6 male 89.8 54.5 32.4 5.7 3.7 3.3 2.9 2.8 1.2 0.9 female male Source: Duscherer&Paulos,2012 In 2013, the same survey was conducted amongst 2,464 partygoers (Duscherer K., Paulos, C. & Kraus A.,2013;Duscherer,K.&Paulos,C.2014).2,379questionnaireswerevalidated.Themedianageofthe participantswas19years,soslightlyyoungerthanin2012.Onequestiondirectlyaddressedparticipants’ druguseduringthelasttwoweeks:ascanbeseeninFigure2.21,alcoholwasagainbyfarthemostfrequent psychoactivesubstancedeclared(82.9%),followedbytobacco(45.9%)andcannabis(22.1%).Allother drugsrangedbelowthe5%mark,likeamphetamines,cocaine,ecstasy,LSD,magicmushrooms,ketamine orheroin. Fig 2.21 Use of psychoactive substances during the last two weeks by partygoers (valid %) (2013) 100 80 60 40 20 0 alcohol female male 79.7 86.8 tobacco 42.8 49.4 cannabis cocaine 16.6 28.5 0.7 3.9 ecstasy 1.1 2.1 female 54 Source: Duscherer&Paulos,2013 ampheta magic mines mushrooms 0.6 2.3 male 0.7 1.9 LSD 0.6 1.9 heroin 0.3 0.9 ketamin 0.2 0.6 Fig 2.22 Use of psychoactive substances during the last two weeks by partygoers (valid %) (2014) 2015 In2014,thesamesurveywasconductedamongst3,796partygoers(Duscherer,K.&Paulos,C.2015).3,679 questionnaireswerevalidated.Themedianageoftheparticipantswas21years,soslightlyolderthanin 2013.Onequestiondirectlyaddressedparticipants’druguseduringthelasttwoweeks:ascanbeseenin figure2.22,alcoholwasagainbyfarthemostfrequentpsychoactivesubstancereported(89.9%),followed bytobacco(49.6%)andcannabis(32%).Allotherdrugsrangedbelowthe5%mark,likeecstasy(4.9%), cocaine(4.7%),speed(3.3%),LSD(1.8%),psilos(1.6%),NPS(1.5%),ketamine(0.7%),ketamine(0.7%) orheroin(0.6%). 100 80 60 40 20 0 Alcohol Tobacco Cannabis Ecstasy Cocaine Female 87.8 47.1 23.5 2.8 2.2 Male 92.3 52.5 52.5 7.3 7.5 Female Male Source: Duscherer&Paulos,2014 55 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 3. PREVENTION INTRODUCTION Capacity building, awareness raising and mobilization of individual resources and promoting protective factors are the main benchmarks as far as national prevention strategies are concerned. Measures may targetthegeneralpublicorselective,specificorriskpopulationsorcommunities. Thepresentchapterprovidesasummaryofrecentuniversalandselectivepreventionmeasuresundertaken atthenationallevel.Moredetailedinformationandexamplesofgoodpracticecanbefoundinthe EDDRA/BestpracticedatabaseoftheEMCDDAunder:http://www.emcdda.europa.eu/themes/ best-practice/examples. Thenational drugs action plan 2015- 2019 addressesprimarypreventionasamaininterventionarea. TheprioritiyareasofdrugpreventionaccordingtothenationalactionplanandtheInterministerialGroup onDrugs(GIT34)areasfollows: • • • • • • • Interventionsinschoolandyouthenvironments,peereducation. Preventioninhomesforyoungstersandsocio-educativefacilities. Interventioninrecreationalandfestivevenues. Cannabis,alcohol,shishaandNPSuseinyoungsters. Massmediacampaigns. Multidisciplinarytrainingprogrammesandtrainingofmultipliers. Documentation,monitoringandevaluationstrategies The National Addiction Prevention Centre (CePT), which has started its activities in 1995, covers drug addictionaswellasthepreventionofdifferenttypesofaddictivebehaviour.LegallyspeakingtheCePTisa foundationco-financedbytheMinistryofHealth. Traininginterventionsindrugdemandreductionareincreasinglydevelopedatthenationallevel.Aspecial department named ’Trampolin’ has been set up within the CePT, to ensure the development of training activities and instruments covering national needs. Target groups are professionals from the educative, social,psychologicalandmedicalfieldsaswellasparentsandotherinterestedstakeholders.Moredetailed informationisavailableontheCePTwebsite35. AsecondimportantplayerinthefieldofprimarydrugpreventionistheDivisionofPreventiveMedicineofthe DirectorateofHealth.Althoughthelattercoordinatesactivitiesinthelargerfieldofpublichealthpromotion and prevention, it plays a major role, jointly with the CePT in the definition of the overall framework of addictionprevention. Theoverallcoordinationofcounselling,treatmentandlowthresholdinterventionsiswithinthecompetence of the Division of Social Medecine, Dependance and Mental Health36and the National Drug 34 GITisanabbreviationfor“GroupeInterministerielToxicomanies”,andreferstotheinterservicegroupforaddictions 35 www.cept.lu 36 The Division of Social Medecine, Dependance and Mental HealthwastranslatedfromtheoriginalFrenchtitle“Divisiondela médecine sociale, des maladies de la dépendance et de la santé mentale”. 56 ENVIRONMENTAL PREVENTION Alcohol policies 2015 Coordinator’s office. TheDivisionofSocialMedecine,DependanceandMentalHealthhascoordination andfinancialcontrolmissions (supervisionoffinancialcontractimplementationofsubsidisedNGOs)inthe fieldofdrugaddictionandpsychiatry.Furthermore,theNationalDrugCoordinatorisresponsibleforthe conceptualisationandtheimplementationofactivitiesincludedinnational drugs action plans. Thelawofthe22thDecember2006prohibitsthesellingofalcoholicbeveragesorofferingofafreealcoholic drinktoadolescentsunder16years.Thislawexpandstheinterdictionofvendingalcoholtoteenagersaged lessthan16yearstoalltypeofcommerces(supermarket,service-stations,etc.).Before,thebanofalcohol saletominorsunder16yearswaslimitedtocafes,restaurantsandbars.InLuxembourgthelegalagefor alcoholconsumeis16yearsregardlessthetypeofalcohol.Thereisnorestrictiononthehoursofsale,daysof salenoronthedensityofalcoholretailers.Thecampaign‘KeenAlkoholënner16Joer–Mirhaleneisdrun!’ (‘Noalcoholunder16years–Westicktoit!’)istargetingtheadultpopulationandthepromotionoftheir responsibility(formoredetailsseerecreationalsettingsunder3.4). Ifabartenderorsalesmanservesorsellsalcoholicdrinkstopersonsshowingapparentsignsofdrunkenness, hecanbepunishedbyafinefrom251to1,000euros. To reduce the sale of alcopops to youngsters, Luxembourg has introduced on the 1st January 2006 a supplementarytaxof1.50eurosper25clonthesedrinks(600eurosperhectoliter).Productscomposedof amixofsodaorjuicewithbeer,wine,anotherfermenteddrink,ethylalcoholandfermentedflavoreddrinks arealsoconcerned. Sincethe1stOctober2007,thelegalbloodalcoholconcentrationisof0.5g/l(before2007:0.8g/l).An alcohollevelof0.2g/linthebloodfornewdriversandprofessionaldrivershasalsobeenintroducedin October2007. Anti-drinkanddrivingcampaignsareregularlyorganizedbytheroadsafetyassociationandtheresponsible youngdriversassociation. The2004governmentalprogrammeputsemphasisonthephenomenonofbingedrinkinganditsincreasing prevalenceinyoungsters.Measuresimplementedaccordingtorecommendationsfromanationalworking groupinitiatedbytheCePTincludedtheabovementionedactionsasasignificantraiseoftaxesimposed onalcopopsandaminimumageof16yearsforthepurchaseofalcoholicbeverages.Italsoincludedthe implementationofthecampaign‘KeenAlkoholënner16Joer–Mirhaleneisdrun!’(‘Noalcoholunder 16years–Westicktoit!’).The2009governmentalprogrammeandthe2010nationalhealthconference initiated the elaboration of a national action plan on alcohol. A special working group chaired by the MinistryofHealthhasreceivedamandatetocontinueitswork. Onthe29thFebruary2012,theMinistryofHealthorganizedtogetherwiththenationalworkinggroupon alcoholacongresswiththeaimofawarenessraisingandmobilizationofpotentialpartnersintheframework ofthenationalactionplanonalcohol.Thiscolloquium,withinternationalexpertsinthefieldofalcohol policy,preventionprojectsandtherapy,hasaddressed3mainsubjects:monitoring,preventionandtherapy ofmedicalandsocialconsequencesofexcessivealcoholconsumption. 57 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Concerning the working plan development, 3 sub-groups were formed for each of the 3 main subjects of the congress. After some preparation work in 2012, a process of discussion was started in 2013 to elaborateconcreteproposalswithexpertsfromdifferentfieldsofpreventionworke.g.pregnancy,children andyoungsters,seniors,workingplace,roadtraffic.Thenationalactionplanonalcoholshouldbefinalized in2016. Jointly with the Ministry of Health, the CePT is participating in the CNAPA, the European Commission ‘CommitteeonNationalAlcoholPolicyandAction’,toshare information,knowledge,compareapproaches ofalcoholconsumptionatEuropeanlevel. Alcoholconsumptionattheworkplacealsorepresentsanimportanttopic,asshowtheresultsfromastudy conductedbythenationalLuxembourgishcouncilonalcohol37 • • • • • 25%ofalltheaccidentsatworkareprobablyduetoalcohol alcoholisresponsibleforevery6thdismissal anestimated8.000to10.000peoplearealcoholaddictedinLuxembourg absenteeismatworkisfourtimesmorefrequentinpersonsshowingproblemalcoholuse almostevery10thworkerdailydrinksalcoholathisworkplace Aconferencewiththesubject‘Alcoholaworkingproblem?’wasorganizedbytheassociationforthewellbeingatworkinthefinancialsector(ASTF)onthe12thOctober2012. In2014,thenationalministersofhealth,workandsocialsecurityofficiallycommunicatedthattheunderlying determinantsofalcoholconsumptionatworkareduetopsycho-socialfactors,suchasstressandanxiety. Theyalsoemphasisedthatthereisastrongneedformorealcoholpreventionattheworkplaceinthefuture. LuxembourgisveryactivewithinthePompidouGroupoftheCouncilofEuropetopromotepreventionof drug-relatedproblemsinworkenvironments. To raise awareness on alcohol abuse at work, a conference was organized in Luxembourg in 2014. The LuxembourgishChamberofcommerce,inpartnershipwiththeChamberofTradeandasupportiveinstitution forenterprises(i.e.“GuichetUniquePME”),organizedaone-dayconferenceentitled“Alcoholanddrugsat work”38.Thisconferencewashostedbyalawyer,whoexplainedthepoliciesinalcoholconsumptionatthe workplace,includingthepreventiverolesandresponsibilitiesofemployersandemployees,andhowtoadd analcohol-relevantclauseinaworkcontract. Alcoholhasbeenresponsibleformorethan40casesofdeathinLuxembourgin2012,accordingtothe dataoftheWHO.Alcoholisresponsibleforthehalfofthedeadontheroadthatis17victimsin2012.The averageconsumptionofalcoholisestimated11.9literofpurealcoholayear,between2008and2012,for aresidentaged15yearsormore.Thisis1litermorethantheEuropeanaverage. With regard to the consumption of alcohol (HBSC 2010), 15% of the 15-year-old girls and 26% of the 15-year-oldboysindicatethattheydrinkalcoholatleastonceaweek.17%ofthe15-year-oldgirlsdeclare thattheywereatleasttwicedrunken,comparedto20%inboys. 37 SchackmannB.(2000).«Alcooletlieudetravail»Guidepourresponsabled’entreprise,cadressupérieurs,gestionnairesderessources humaines,membresdescomitésd’entrepriseetdélégationsdupersonnel(CNLA). 38 WetranslatedthetitlefromtheoriginaltitleinitiallyexpressedinFrenchas“Alcooletdroguessurlelieudetravail” 58 Inaddition,thepromotionofafakecampaign‘LuxDrinkDrive’-adrive-inforalcoholicandnon-alcoholic beverageswaslaunchedin2014.Theslogan‘yourcocktailsstraighttoyourcar’39wasexposedwithapicture ofcocktailsservedfromadrive-inwindow.Therealpurposesofthispreventioncampaignwererevealedsoon afterthefirstpromotionwave. 2015 Acampaign‘Raoul:drinkordrive’cameoutin2012withbighoardingsalongthemaintransportaxis,small postersincafes,pubsanddiscos,aswellasacinemaspot. In2014,the‘Raoul’campaignwasreissued.Theyusedapictureofatequilaglass,withtheslogan“ateKILLAshot?”(translatedfromFrench“unshotdete-KILLA?”),whichwascommunicatedthroughpostersin busshelters,andelsewhere. As a follow-up, the road safety association has hosted a press conference on their campaign “Lux Drink Drive”,inDecember2014.Theircommunicationsuggestedthatadultsolderthan25yearsoldaremore awareandmoresensitized,againstthe16-25yearoldpeople,whoneedtobefurtherpersuadedontherisks associatedwithdrinkinganddrivingbehaviors. In2014,theTNSIlreshasstudiedalcoholconsumptionanddrivingin503participantsagedbetween15-29 yearsold.Ofthetotalsample,59%statedthattheyhavealreadydrivenacarafteralcoholconsumption, and70%ofthesampleadmittedtohaveco-driveninthepastwithadriverwhohadconsumedalcohol, whereas91%ofthesamplehaveavoidedalcoholconsumptioninthepast,inordertosafelydrivehome theirfriends. TheMinistryofHealthintroducedanewcampaignin2013entitled‘0%ofalcoholduringpregnancyand breastfeeding’.AnationalalcoholactionplaniscurrentlyelaboratedbytheMinistryofHealth. Tobacco policies Thelawofthe11thAugust2006: • Thepublicityinfavouroftobacco,ofitsproducts,ofitsingredients,aswellaseveryfreedistributionofa tobaccoproductareforbidden.Thisbanincludestheuseoftheemblemofthebrandorthenameofthe tobacco,oftobaccoproductsaswellaseveryotheruseofrepresentationormentiononcommonobjects otherthanthosewhoaredirectlylinkedtotobaccouse. • Thesaleoftobaccoproductstominorsunder16years(everycarrierofcigarettesvendingmachinesand othertobaccoproductsisboundtotakemeasurestopreventtheminorsunder16yearstoaccessthese machines)isforbidden. • The smoking in certain public places (in schools settings, hospitals and site (except smoking room), publicmeansoftransport,sportscentres,supermarkets,restaurants(exceptsmokingroom)aswellas barsandcafesofferingmeals(interdictionbetween12-14and19-21hour)isprohibited. Thegrand-ducaldecreeofthe31stOctober2007forbidssmokinginalltheStatebuildings,municipality buildingsandpublicfacilities. Ifapersonsmokesinaplacewhereitisforbidden,thepoliceorcustomofficecanissueafineof24euros.If thesmokerisnotabletopay,refusesorifhe/sheisminor,thecourthastosetthepenaltytopay(between 25-250euros).Concerningthemanagerofarestaurantorcafe,ifhe/sheneglectsconsciouslytheban,a finecanbeimposedrangingfrom251to1,000euros. 39 WetranslatedthetitlefromtheoriginalFrenchversion“emportezvoscocktailsauvolant” 59 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Anewanti-tobaccolawhasbeenvotedonthe2ndJuly2013andcameintoeffectonthe1stJanuary2014. Thisnewlawhastwomajorgoals,namelytoprotectthehealthoftheemployeesincafes(frompassive smoking)andtopreventtheyouthofsmoking.Thefollowingchangeswereappliedfromthe1stJanuary 2014,onwards: • Totalprohibitionofsmokingindiscos. • Totalinterdictionofsmokingincoveredbuildingswheresportsandleisuretimeactivitiesarepracticed. • Prohibitionofsmokingincafes,restaurantsandfacilitiesofcollectiveuseinhotelswiththeexception ofspecificallydesignedsmokingrooms. TheLuxembourgishgovernmenthasadoptedagrand-ducaldecreeincreasingthetaxontobaccothe1st February2014.Thisriseappliestocigarettes,tobacco,cigarsandsmallcigars. In 2009, a national tobacco plan has been developed to prevent and reduce tobacco consumption and relatedhealthrisksbydefiningthe3followingmajorobjectives: 1) Topreventthetobaccoconsumption(toreducetheprevalenceinyounggirlsandboys,todelaytheage ofthefirstconsumptionandtostoptheprogressionoftobaccoconsumption) 2) Toreducetheconsumptionoftobaccoincurrentusers(topromotetheobjectiveinformationonthe product,topursueachangeofbehaviourinthelongtermandtostimulatedetoxificationtreatment) 3) Toprotectthenon-smokersfrompassivesmoking(toprotectthehealthandrightsofnon-smokers) 7strategieson3levelsareincludedinthisnationaltobaccoplan: Structural level • Policyofpricesandtaxesontobaccoproducts • Responsibilityoftheindustryandcontroloftobaccoproducts • Protectionagainsttheexposureoftobaccosmoke Behavioural level • Preventionoftobaccoconsumption • Assistancetostopsmoking General level • Researchandevaluationoftheactionsmade • Developmentofthenetworkingandcollaborations Thelawofthe11thAugust2006regardingthesecurityandthehealthoftheemployeesemphasizesthat theemployerhastotakeallthemeasurestoensureandimprovetheprotectionofthephysicalandmental healthoftheworkers,particularlybytakingtheappropriatemeasurestoprotecttheemployeeseffectively againstthesmokeresultingfromthetobaccoconsumptionofothers.Thelawencouragestheemployerto protectthenon-smokersfrompassivesmokingattheworkplace.Therearenomandatoryinstructions,but an obligation of a result.In practice,theaim istohaveworkingplaceswithoutsmoke,butnotwithout smokers. AstudyonthesmokinghabitsinLuxembourgwasconductedin2013byTNSIlresforthecancerfoundation including3,658personsagedmorethan15years.Luxembourgcounts21%ofsmokers,ofwhich16%are dailysmokers.24%ofthemalepopulationissmoking,comparedto19%ofthefemalepopulation.Concerningtheage,especiallyyoungpeoplebetween25and35(29%)aresmokers.Regardingthepercentage ofsmokerswillingtostop,60%ofthesmokerswouldliketostopsmoking.Astothequantityoftobacco 60 IntheHBSCsurvey(2010),26%ofthe15-year-oldgirlsdeclaredthattheyalreadysmokedattheageof 13(oryounger),against29%inboys.19%ofthe15-year-oldgirlsreportedthattheysmokeatleastoncea week,versus22%forboys. Themaintaskofpublichealthpoliciesconsistsintheprotectionofthehealthofthecitizens. Aseriesofassociations(noexhaustivelist)assistpersonswhodecidedtostopsmoking: • TheLuxembourgishfoundationagainstcancerhasahelpline,called‘Tobacco-Stop’wherepeoplecanget information(onthebenefitsofstoppingtosmoke,onthedifferentexistingmethodstostopsmoking,…), advices(testofmotivation,testofdependency…)andhelpfromanexpertintobaccodetoxification. • The“redcross”organizationhasaprogrammetoassistatdetoxificationcalled“Smoke-freein4steps” fortheyouthondemandinalltheyouthcentres. • TheCePThasorganizedadvancedtrainingsondetoxificationforthestaffinschools,incooperation withtheSCRIPT. • The “ligue médico-sociale” offers different services: motivational discussions and free counselling for smokersintheircentresofLuxembourg,EttelbrückandDudelangetohelpthemwiththeirdetoxification. Moreover, they provide sessions of awareness raising on detoxification in schools and assistance for detoxincompanies.Furthermore,theyorganizetrainingsforprofessionalsinthehealthsector. • Occupationalmedicalservicesalsoprovidedetoxificationcoursesoftobaccointhecompanies. 2015 consumption,48%smokehalfapacketofcigarettesaday,against44%smokinghalfapackettoapacket ofcigarettesadayand8%smoking1to2packetsaday.21%ofthepopulationagedbetween15to24 yearsreportedshishasmoking,againstonly5%ingeneralpopulation. TheMinistryofHealthlaunchedanewcampaignagainsttobaccowiththefollowingslogans:’Startingto smoke,thereisnothingmorestupid’,‘Beclever,neverstart!’and‘Choosealifewithouttobacco’.Inaddition,aphotocontestwithselfieswasincluded,whichwasintendedtoshowthatsmokingdoesnotappear attractiveoradultinanyway. Since2011,aninterventioncampaigncalled“Ex-smokersareunstoppable”hasbeenorganizedbythepublic healthdepartmentfromtheEuropeanCommission.Thiscampaigntranslatesinformofasmartphoneapplicationnamedafter“iCoach”.Itwasreeditedin2012andin2013.Asindicatedbytheirnewsletter,the nexteditionisplannedfor2015.Untilnow,thesuccessrateofthosewhodefinitelyhavequitsmokingafter takingthisprogramme,liesapproximatelyat30%ofparticipants. UNIVERSAL PREVENTION School Addictionpreventionprogrammesinschoolsarenotmandatory.Nationaldrugpreventionactivitiesintegratedwithinnationalschoolprogrammeshavemainlyresultedfromcorporate actionsofdifferentgovernmentalandnon-governmentalactors:MinistryofFamilyandIntegration–NationalYouthService(SNJ), MinistryofHealth-DivisionofSocialandPreventiveMedicine,MinistryofNationalEducation–Serviceof CoordinationofResearchandofPedagogicalandTechnicalInnovations(SCRIPT)/PsychologicalCareand EducationalOrientationDepartment(CPOS)andsince1995,CePT. TheCPOSispermanentlyrepresentedinallsecondaryschoolsbyatleastonetrainedpsychologistandseveraladhocteachers.Inmajorschoolstherearesupplementarytrainedsocialworkers.Amongothertasks, theyaresupposedtodetect,attheveryearlystage,problemsorbehavioursinrelationtosubstanceabuse. Drugandaddictiontopicsareincludedinmoregeneralcoursesasforinstance,hygieneorethics,which mightnotbemandatory.Furthermore,theGrand-DucalPoliceorganisesschoolcoursesforthe6thclasses ofprimaryschooland7thclassesofsecondaryschoolsprovidedbyspecializedpoliceteamsoutofregional policeunitsandfromthedrugdepartmentoftheJudicialPolice. 61 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 In 2000, the CePT in collaboration with the SCRIPT, started a pilot project called ‘d’Schoul op der Sich’ (School on quest)(seeEDDRA)runningfortwoyear’sandhavingbeenevaluatedin2003.Theaimofthis participativeprojectconsistedincreatingso-calledpreventiongroupsamongallparticipatingsecondary schoolsinordertoinitiateaprocessofreflectionondrugrelatedthemes.In2004,theCePTmanagedtoset upaprimarypreventiontooladjustabletotheneedsofthedifferentsecondaryschools.Preventiongroups arenowoperatingroutinelyinseveralsecondaryschoolsinordertofindsolutionsthatfiteachparticular context. Inthiscontextafurtherdevelopmentstagehasbeenreachedin2009bythelaunchoftheCePToolbox. This‘box’includesthenecessarytoolstounderstandandpromotelifecompetencesofchildrenandteenagers from3to15yearsandaccompanythemontheirwaytoautonomy.Thetoolsaredesignedforthreeage categories: 3-6, 7-11 and 12-15 years. The referred instruments are primarily meant to serve educators, pedagogues,psychologistsandteacherstoassistthemintheirprofessionalactivities.TheCePTalsooffers trainingsonhowtousethesetools.TheCePTtoolboxcanbedownloadedat:http://cept.lu/fr/trampolin/ formations/materiel-didactique(seealsosectionfamily). From2009to2012,inthecontextoftheMAG-Netinschool(whichisapartoftheINTERREGIVAproject MAG-NET),twoprimaryschoolshaveparticipatedinthispilotproject.Allinall,13membersoftheschool staff,120studentsaswellasstudents’parentswereinvolved.Threemodulesoftwohourswereproposedto thestudentsinclass.Thesubjectstoucheduponduringtheseinterventionswerethefollowing:emotionsand empathy,needsandcapabilities,thestrictuseofrulesandlimits,aswellaspersonaldecisionsandopinions. Between the modules, the teachers have revised the new notions with the students by proposing them creativeactivitiesandpracticalexercises.Theinterventionsinclasswereevaluatedbymeetingsbetween educationalstaffandtheinstructorandbyquestionnairesforthestudents,theparentsandtheeducational team.ThefinalreportwithadocumentationoftheprojectMAG-Netinschoolandacollectionoftoolsfor schoolswaspublishedin2012.Inthisframework,aninterregionalconferenceoftwodaysfocussingonbest practiseexamplesandtheexchangewith40participantsfromtheGreaterRegionhasbeenorganisedin February2012.http://cept.lu/wp-content/uploads/dmdocuments/Schule-MAG-Net_Luxemburg.pdf In 2014, the CePT acted within the scope of different basic trainings. Most of these modules are in the meantimewell-establishedintheappropriateeducationstructuresforseveralyears. For teachers and professionals from the educative, social and psychological fields at school the CePTTrampolin-Departmentorganizedfurthertrainingsnamelyintheframeworkofthecollaborationwiththe SCRIPT. In 2014, there were several trainings on psychotropic substances, different methods and tools availableforthepreventionofaddictions. AnewmodulewaselaboratedbytheCePTin2011,forprofessionalsactinginnon-formalyouthworkand dealing with children and adolescents. The aim of thistrainingwasthecommunicationwithyoungsters regardingpsychotropicsubstances. In2014, theCePTalsoofferedintroductivecoursesonpreventionofaddictionsattheLuxembourgishPolice academy,andattheUniversityofLuxembourg. InthecontextofhonoraryofficeatrainingcoursewasconductedforyouthleadersoftheLuxembourgish YoungFirefightersAssociationintheframeworkoftheirleadershiptrainings. In2012,atrainingworkshop,called“Fairytalesondrugs”,wasorganisedforthestaffoftheLycéeTechnique d’Esch-sur-Alzette,theLycéeTechniqueBel-Val.Inmanyfieldswrongorincompleteinformationondrugs andaddictionarecirculating.Thisworkshopaimedatreconsideringtheactualknowledgeonthesubject. 62 Trainingsdeployedin2014: Belowarelistedtrainingsprovidedin201440. Thefollowingtrainingsaddressedcommonknowledgeonsubstances: Fairy tales on drugs (Drogemärercher, Nach méi Drogenmärercher) Alotofwrongorincompleteinformationondrugscirculatesatdifferentlevels.Thereferredworkshopaims atreconsideringthecurrentknowledgeonthemostcommonlyuseddrugs.Whichpsychotropicsubstances areconcerned?Whataretheirconsumptionmodeandtheireffects?Whataboutthecurrentlegalstatus? Howtochoosetheappropriateinformationtoprovidetoadolescents? 2015 TheworkshopwasalsoproposedasadvancedtrainingbytheSCRIPTforagroupofteachersfromdifferent secondaryschoolsandbytheSNJforagroupofeducatorsofdifferentyouthhouses.Anotheradvanced trainingwhichwasproposedin2012hadthefollowingtheme:“LegalHighs–Spice,BathSalts&co.” Thetrainingfocusedontheacquirementandtheconsolidationofbasicknowledgeonthemostcommon psychoactivesubstancesandshouldenabletheparticipantstoaskthequestionstheyalwayshadabout drugconsumption. In2014,thistrainingwasprovidedtoprofessionalsfromsocio-educativefieldsandteachers.Inaddition, a follow-up training was provided. This new training on the “Fairy tales on drugs“ is meant to explore syntheticdrugsinmoredetail.Thetrainingprovidesinformationonacurrentrangeofsuchproducts,their consumptionpatternsandtheireffects,theirmarketingmethodsandthelegalframeworkinLuxembourg. Legal Highs Thetrainingaimsatclarifyinginformationonnewpsychoactivesubstances,(NPS,Legal Highs). In2014,thistrainingfocusedonnewsubstances,theircurrentmarketstatus,theircompositionandthe legalframeworkaroundNPS.Teachers,educatorsandpsychologistswerethemainaudienceinthistraining. Thefollowingtrainingsaredealingwithlifeskillseducation. Trampolin - Sprongkraaft am Alldag Thisadvancedtrainingisanintroductiontothepreventionofaddictionandcommunicatesup-to-dateinsights inthefollowingcontents:approachesofthepreventionofdependencies,parametersforthedevelopment ofdependencies,understandingofdrugpreventionworkinthecontextofhealthpromotionandlifeskills promotion,presentationoftheCePTmodel„Trampolin“,behaviouralandsituationalpreventionaslevelsof prevention.Moreover,specificcoursesofactionarealsopresentedanddiscussed. Thisadvancedtrainingservesasabasicmoduleandasfoundationforothermodulesaspartofaspecial offerfromtheCePTforthesecondaryschool. Training on the application of the didactic tool « Cannabis - Quo Vadis? » A new training workshop aims to educate a group of teachers or educators to use the educational tool « Cannabis–Quovadis?»issuedbytheVillaSchöpflin.Thistoolconsistsofexerciseswhichallowapproaching theissueofcannabisconsumptionwithschoolclassandadolescents.Theseexerciseshelptocommunicate neutralinformationoncannabissuchasthepsychoactiveeffectsofthesubstanceanditslegalstatus.Other exercisesapproachthetopicofchoiceandindividualfreedom,biographicalcareerorallowtoworkonthe 40 http://www.cept.lu/ 63 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 changeofperspective(adolescent,parent,teacher)aboutcannabisconsumption.Thistoolcanbeusedfor freefromtheCePT:www.cept.lu/fr/trampolin/formations/materiel-didactique. In 2013, this training has been carried out as internal advanced training (SCHILW) for the staff of the «LycéedeGarçons»inLuxembourgandfortheemployeesoftheCPOS(PsychologicalCareandEducational OrientationDepartment).Ithasalsobeenheldintheframeworkoftheofferofadvancedtrainingfromthe SNJforagroupofeducatorsfromdifferentyouthhousing. Kanner staark maachen am Sport (Give strength to children in sport activities) IncooperationwiththeSNJ,theCePTorganizedtrainingsforprofessionalsofyouthassociationsandyouth clubs,focussingondifferenttopicsofaddictionpreventionwork. In2014,theCePTcontinueditsclosecollaborationwiththeNationalSchoolforPhysicalEducationand Sports (ENEPS) in the framework of a project called ‘Give strength to children in sport activities’ called (Kanner staark maachen am Sport). Sports activities are used as a framework and a tool for preventive action.Themaingoalofthisprojectconsistsinstimulatingself-confidenceofadolescentsandtostrengthen them. More information is available under: http://cept.lu/fr/trampolin/formations/historique-desformations/725-kanner-staark-maachen-am-sport Lifestyle: Drugs, Sex and Rock’n Roll (Drogues, Sexe & Rock’n Roll (Risflecting ©)) This training approaches the subjects of prevention and health promotion in a practical way. These two topicsarecloselylinkedtolifestyles,consumptionpatternsanddecisionmaking.Throughoutthistraining thenotionofwell-beingislinkedtothenotionsofpleasure,risktakingandindependence. Adolescenceisperseaturbulentperiodoflife.Youngstersdiscovernewactivitiesandmakenewexperiences oftenassociatedwithhedonismandrisktaking:theconsumptionofdrugs,romanticrelationships,sports andrecreationalactivities. Thefollowingquestionsareaddressed:Howtoleadagroupofyoungstersforwhichrisktakingisadeliberate behaviourorwayoflife?Whichactivitiesshouldbeproposed?Howtoprepareforit?Howcanweplacethese activitiesinaframeworkofeducationalwork? In2014,thistraininghasbeenprovided,incollaborationwith4motion a.s.b.l.,(throughtheofferofadvanced trainingbytheSNJ)tothestaffofyouthcentresandyouthorganizations. Thistrainingcyclecomprisesasingleblockof20hours,overtwodaysandonenight.Theimportanceof drugsinoursocietyandourcultureisraisedanddiscussed,byfocussingonthedrugwhichinourcultureis intimatelylinkedtopartying,namely:alcohol. Theorganizationofpartysisanintegralpartoftheworkwithyoungpeople,andoneofthefirstquestions thatarisesisobviouslythepresenceornotofalcohol.Thus,thisopportunityfordiscussionmaybetaken intoaccountinthepreparationworkofaparty,andcaneasilybeillustratedbythemodeloftherisflecting© approach. Therefore this approach recommends an original method to support young people in their experienceswithdrugsandotherrisktaking. Applied addiction prevention (“Suchtprävention in der Praxis”) This training consists of a presentation and discussion on the roles and responsibilities of professionals fromeducationalandyouthaggregates,andtheircontributiontoprevention.Italsorecommendshowto applydrugabusepreventionintheirdailywork.In2014,theCePT,inpartnershipwiththeLuxembourgfire departmentorganizedthistraining. 64 When I grow up… All I ever wanted to know about drugs (“Wann d’Kanna-bis grouss ginn…. Wat ech nach ëmmer iwwer Droge wësse wollt!”) In2014,ameetingdedicatedtocannabiswasorganizedbytheCePT.Themaintopicswereongeneral information about cannabis, practical exercises on how to discuss cannabis with young people, and a promotionofthetherapeuticserviceforyouthcalledIMPULS(STSJ41). 2015 Alcohol and Cannabis (“Alkohol und Cannabis”) This training provides an overview on the current situation of alcohol and cannabis in Luxembourg and recommendations on how to initiate a discussion about alcohol and cannabis with youngsters. In 2014, thistrainingwasorganizedbytheCePTandtheSNJ.Theiraudiencewasateamofvolunteers,whowere planningtowork,orwerealreadyworkingwithyoungpeople. Recommendations on how to introduce cannabis-related preventive actions in schools (“Cannabis und Jugend – Handlungsmöglichkeiten um das Thema Cannabis in der Schule zu thematisieren”) This training aimed at explaining cannabis consumption in adolescents, and, more specifically, how to discussitwithyoungpeople.Theemphasiswasputonencouragingyoungpeopletowardscriticalthinking oncannabis.ThistrainingwasdesignedbytheCePTandtheSCRIPTforprofessionalsatschools. Hugo, Trojka & co. – how to discuss alcohol consumption with adolescents (“Hugo, Trojka & Co – Wie mit Jugendlichen Alkohol thematisieren”) Alcoholislegalandalmost‘normal’inoursociety.TheCePT,inclosecollaborationwiththeSCRIPThas offeredatrainingonalcoholandalcopopsforsocio-educativeprofessionals.Examplesonbestpracticeand recommendationsonhowtoguideyoungsterstowardsareasonedalcoholconsumptionwerepresented. Other professional settings Wednesday’s seminars EveryfirstWednesdayofthemonth,theCePTinvitesnationalandinternationalexpertstosharetheirarea ofexpertisewithcolleaguesworkinginrelatedsectors.Thetopicsare,insomeway,connectedtodrugsand dependencies,aswellastohealthpromotion. In 2014, the Wednesday’s seminars focused on various drug-related topics. For instance, one of their seminarswasdedicatedtothe“0%ofalcoholduringpregnancyandbreastfeeding”,whichwasorganised inpartnershipwiththeMinistryofHealth. Anoverviewofthecooperationofthejudicialpoliceandcustomsservicesinthefightagainstdrugstrafficking andterrorismhasbeenpresented.Thepresentationfocusedonthecurrentlegislativedevelopments,the internationalpolicecooperationaswellastheinspectionandinterventionwork. Furthermore,thepreventioncomponentfromthegrand-ducalpolicewasoutlinedinapresentationofthe missionsofthelatterintheregionaldistricts. The prevention work with the youth through the incorporation of risk and its consequences was also approached. That particular Wednesday seminar was presented in parallel to a workshop http://rotondes.lu/agenda/details/event/risflectingc-leben-in-rausch-und-risikobalance/ and illustrated bytheexampleofriskmanagementduringalcoholconsumption. 41 STSJisanabbreviationfor“ServiceThérapeutiqueSolidaritéJeunes”andreferstotheTherapeuticservicefromtheYouthSolidarity agencyrenamedin2014toIMPULS 65 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Furthermore,aninterventionfocusedontheexecutionofaprojectfromUpperAustriawhichintendedto improvethecurrentsituationconcerningpreventionatthemunicipalandregionallevel. EuropeanpartnerswereinvitedtoshowproceduresofdrugcheckinginSwitzerlandandinSpain,aswellas theirexperiencerelatingtodrugcheckingasaninstrumentofriskreductionduringrecreationaluse. In2012severalexchangemeetingsofthesocialMAG-Net(whichispartoftheINTERREGIVAprojectMAGNet)fortheprofessionalrepresentativesofthesocialsectoroftheGreaterRegion,attractingmorethan100 expertswerehold. In the course of the programme INTERREG IV A Greater Region 2007-2013 (Project 128 GR DELUX 3 3249),theCePTlaunchedanewinterregionalproject(foradurationof2years)inJanuary2013entitled MAG-Net2–RiskreductionrelatedtorecreationaluseofdrugsintheGreaterRegionandawareness-raising ofhealthprofessionals. InvolvingsixinstitutionsandassociationsoftheGreaterRegion,themainobjectiveofMAG-Net2consists in the development and offer of trainings and exchange meetings on recreational drug use specifically aiming at employees from the health sector. The updated training offer is available on the website42 (http://mag-net.eu/category/events/). In2013and2014,respectively,36and31interregionaltrainings,conferencesandseminarswereorganised bytheInterregIVAprojectpartners,withrespecttotheMAG-Net2project. In2014,theCePTdesignedacampaignforlaymen,whoarenewcomerstodrugusingclientsinhealth settings.Inordertocomplementthetraining,relevantposters,postcardsandaninformativebookletwere publishedanddistributedtoMDs,medicalcentres,conferences,andpersonnelfromhealthaggregatesat the Greater Region. They designed specific postcards with relevant information on most common drugs, whichweretobacco,alcohol,cannabis,ecstasy,LSD,speed,cocaineandNPS.Thebookletwaseditedin French and in German, and included a description on the physical and psychical consequences of drug abuse,howtoreactincaseofadrugrelatedemergencyandalistwithusefuladdresses.InLuxembourg, 2,153bookletsand48,416postcards(i.e.6,052setswith8cards)weredistributedtohealthaggregates, bytheendof2014. Thecontentsofthetrainingsandexchangemeetingsarebasedontheresultsofsurveys,interviewsand focused groups, which were conducted with users of the Greater Region on their current drug use. A particularattentionwasgiventotheconsumptionofalcohol,LSDandnewsyntheticproducts(NSP,orLegal Highs).InLuxembourg,317interviewswereconductedwithusersindifferentcontextsofleisure:theparty scene(musicfestivals,concerts),thesportscommunity(gym,footballclub),theschoolgrounds(high-school, university),aswellascommunitygroupsforelderlypeople.Also,focusedgroupswithrecreationaluserswere organizedinordertoidentifythesocialrepresentationsofdrugconsumption. In2014,finalresultsfrominterviewsandfocusgroupswerepublished.Theprojectrecordedanumberof 1,381participantsfromfestiveareas,sportsclubsandelderlycommunities.Thesurveyshowedthatthemost frequentlyconsumedrecreationaldrugsarealcohol(consumedby63.4%),followedbycannabis(38.5%), and tobacco (31.2%). Other “party” drugs consumed within the sample were magic mushrooms (6.2%), cocaine(6.2%),amphetamines(5.8%)andecstasy(5.7%).LesspresentwereLSD,NPS,pharmaceuticals, poppers, ketamines, and heroine (between 0.9%-3.8% of use). The evaluation of the distribution of the festive, scholar, sports and senior areas and different age groups (13-17 vs 18-25 vs 26-50 vs 51-95) 42 http://mag-net.eu/category/events/ 66 In2014,the15theditionofthecompetition‘Missiondonotsmoke’tookplaceinLuxembourg,toinform adolescentsonthedangersoftobacco.Thecompetitionaddressedtoalltheschoolclassesofthecountry withstudentsagedbetween12and16years. Thepreviousedition(from2013)reachedarateof89smoke-freeclasses,fromatotalof129participating classes,including2,525students. CoordinatedbytheMinistryofNationalEducation-SCRIPT,amobileinteractiveandpreventioninstrument calledthe‘Extra-TourSuchtLëtzebuerg’andaimingtoreachstudentsaged15to18yearsinsecondary schoolsettingswasfurtherdevelopedandadaptedforinstancetonewtrendssuchasshishasmoking.Itwas specificallydesignedfortheLuxembourgishschoolsettingsbytheGermancompanyKomPass.Interactive intervention modules are applied alternatively and allow the participation of 60 pupils. Currently the followingthematicsessionsareproposed: 2015 replicatedthesequenceofthedrugpreferencefromthissample,withanobviouspredominanceofalcohol, followedbycannabisandtobaccouse.Theauthorsalsoreportedgenderdifferencesindruguse,withhigher valuesinmenthaninwomen. • Tobacco–Lustforlife • Dependenceandpleasure • Lifeskills–Fitforlife • Norms–Newworld • Alcohol–Towinandtoloose Theactualversionofthe“Extra-TourSuchtLëtzebuerg”wasinitiatedin2009byKomPassandaworkgroup (SCRIPT,MinistryofHealth,LigueMédico-sociale,CePT).“Extra-TourSuchtLëtzebuerg”wasevaluatedin 2012. 107 questionnaires, mainly completed by class teachers and staff from the SPOS of the different schools,wereanalysed(returnrate:81%).Themainresultsaredescribedinthefollowingsummary: • Thetoolwasdeemedtobeadequateasacademicinstrumentforpreventionofaddiction(91.4%)and thebasicconceptwasconsideredtobeappropriate(93.9%). • 28%ofthemoderatorswereparticipatingforthesecondtimeormoreofteninthe“Extra-TourSucht Lëtzebuerg”. • Theassessmentsfortheindividualstationsreachedanaverageof90%approval.Thestationsoftobacco andalcohol,newlydevelopedin2009,wereconsideredtobemeaningfulwith94.5%. • Themoderator’sinstructionscommunicatedforthemostpeopleimportantknowledgeofthecontent andthepractice. • Relatedtoquestionsaboutthemoderator’sfolder76.4%indicatedthattheyfeltmotivatedtodwell onpreventionofaddiction.Thedidacticmaterialswereconsideredtobeagoodfacilityforthepost processinginclass(78%). • Thereactionsofthestudentsweremainlypositive,especiallyrelatedtointeractivemethods(91.8%)and totheencouragementofthepersonalreflexion(89.3%). • Thetoolmotivatestodiscusspreventionofaddictionandenablesacademicactorstoact.Almostall participants(97.1%)indicatetorecommendthetoolrespectivelytoparticipateagain. • 92.6%ofthemoderatorsweremotivatedtopursuesuchoffersortomakeownbidsinfuture. Analysingdataonparticipation,thefollowingnumbershavebeenretained:peryear5to7applicationstake placeonaverage,sothatapproximately1.500studentsand60formedmoderatorsarereached. Jointly with the STSJ, the CePT developed a brochure on cannabis especially designed for teachers and otherprofessionalsoftheeducationalsector:« School and cannabis – Recommendations for School staff ».TheMinistryofNationalEducation-SCRIPTpublishedthesecondedition:«The cannabis consumption among young people – a challenge for school staff» in October 2012. It includes epidemiological data, 67 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 recommendations on early recognition, prevention and intervention means and information on existing networks.http://cept.lu/?attachment_id=1343 A further component of the CePT’s work is the promotion and implementation of addiction prevention projectsincooperationwithschoolsandalsoyouthclubs.Theproject‘Nach ëmmer Allc‰l’wasdeveloped jointlybytheCePT,theNationalTheatreofLuxembourg(TNL)andSCRIPTforthesecondaryschools.The outcome was a theatre play, addressing prevention of alcoholism presented in secondary schools from JanuarytoMarch2009reachingapproximatelyanaudienceof1,300persons.Afterthe1steditionin2009, aneweditionoftheproject‘Nach emmer Allc‰l’tookplaceinNovember2011.ADVDwasproducedby theMinistryofNationalEducationin2012,whichispartofdidacticmaterialforalcoholpreventioninschool elaboratedbytheCePTasaneducationalworkbooktobepublishedbytheSCRIPT. In2013,arelevanteditionof“TheInsider”magazinefromcancerfoundationaddressedadolescentsaged between 12 and 16 years. The cover asks: “What does alcohol do to you?” This edition tries to give the youthanunderstandingofthehandlingofalcoholbyfieldreportsfromotheryoungpersons.Furthermore, itinformedthatbingedrinkingcancausedeath,thatalcoholicdrinksarefairlycalorificandthatalcohol consumptionhasanegativeeffectonthememoryandconcentration. In2014,“TheInsider”furtherfocusedonpreventionofsmokingbehavior,aswellasby-productattributes that young people associate with smoking (i.e. “smoking is cool”). This magazine is usually available at schools,medicaldoctor’sofficesandrecreationalareas. Finally,trainedpolicestaffperiodicallyvisitsvariousschoolsofthecountry,toinformstudentsondrugsand theirrisks.Thesepreventionofficersmeeteveryyeararound6,000students. Moreover,theLuxembourgishPolicehasdedicatedtwosectionsondrugabusepreventionontheirwebsite, oneforadultsandparents,andoneforadolescentsandyoungpeople. Family Eventhoughinterventionsaimingatthepromotionofpositivelifeexperienceswithinthefamilyandthe kindergartenarenotexpressivelyaddressedinthenationaldrugpreventionactionplan,therearelocalor regionalinitiativesfocusingoninformationandadviceprovidingtoorganisationofparents’eveningsduring whicheducationalandhealthtopicsarediscussed. Active collaboration between the CePT and parents’ associations at each education level does exist : Fédération des Associations de Parents d’Elèves du Luxembourg - FAPEL; Kannerschlass Foundation - ‘Parents’School’;Ombuds-Comitéfird’RechtervumKand–ORK;EntentedesFoyersdeJoura.s.b.l.-EFJ. ThecooperationbetweentheCePTandtheparentingclassesJanuszKorczak(Kannerschlassfoundation) continued in 2013. Some new recommendations for parent-teacher conferences for parents of children between0and15yearsarebeingelaborated.Theparent-teacherconferenceswillbeproposedaftertheir completionandthisbytheprogrammeoftheparentingclasses. Thefirst‘preventionbox’,targeting3to6yearsoldchildrenandincludingdidacticmaterialdesignedfor potentialmultipliersasforinstanceteachers,parentsandyouthanimatorshasbeenreleasedinSeptember 2001.In2004,seminarsonthe‘preventionbox’tookplaceindifferentcommunitiesparticipatinginthe projectofaddictionpreventioninlocalcommunities.Also,theCePTcollaborateswiththeKannerschlass Foundation,intheframeworkoftheproject‘Parents’School’.Duetoitssuccess,theCePTextendedthe ‘prevention box’ and finally published the CePToolbox in 2009 with three age categories: 3-6, 7-11 and 12-15years. 68 Since2014,thenationalPolicehasshownincreasedinitiativesintermsofdrugprevention.Theirinformation ismainlyavailableforparentswhowouldliketolearnmoreaboutdrugs,ontheindicatorsandsymptomsof druguseandabuse,thehealthconsequences,therisksandcrimesassociatedwithdrugs,andtherelevant lawsandpolicies. 2015 Since2013,theMinistryofHealthhasbeenpromotingitscampaignonalcoholconsumptioninpregnant womenandyoungparents,named‘0%ofalcoholduringpregnancyandbreastfeeding’43.Theimplementation took place in form of an informative brochure in German and French, and was promoted through GPs, pharmacies,healthcenters,andsocialinstitutions. Community Asmostofdrug-relatedinterventionsandstrategiespreventionincommunitysettingsareorganisedcentrally and nationwide, projects are rarely initiated by the local community level without close collaboration of nationalauthorities. Generallyspeaking,localandregionalcommunitiesdorarelydisposeofacomprehensiveaddictionprevention strategy.Commonly,agivennationalagencyinitiatesprojects,definesthegeneralinterventionframework andseeksactivecollaborationwithcommunityauthoritiesinordertomeetlocalneeds.Atpresentonlyone agencyfocusesoninterventionsinrecreationalsettings,namelytheCePT(communityproject44). In 2004 the CePT started the project ‘adventure circuit’ with more than 40 volunteers and developed an instrument for interactive and tangible drug prevention targeting general population. This itinerant exhibition finally called ’TRAMPOLIN – Sprongkraaft am Alldag’ was presented from 2005 to 2007 in severalplacesalloverthecountryofLuxembourg.Sincethen‘Trampolin’isusedbytheCePTasasymboland amodeltoexplainthebasicsofaddictionpreventione.g.initstrainingsanditspublications. In2013,fortheEuropeanyearofthecitizens,whichshouldbetheyearofallthecitizens,includingthemost vulnerable,therepresentationoftheEuropeanCommissioninLuxembourgsupported,togetherwiththe collaborationoftheMinistryofHealth,aprojectcalled‘Alltogether’.Thecrucialdateofthisinitiativewas the08June2013,thedayoftheNightMarathonING.Morethan200runnerswereparticipatinginthis project.Partnersoftheprojectwerethefollowingassociations:‘Jugend-anDrogenhëllef’,thetherapycentre ofManternachandthe‘SchaumbergerHof’oftheSaarlandinGermany.25formerdrugaddictstrained duringweekstogetintoshapeandtoparticipateinthismarathon.Thegoalofthisprojectconsistedin facilitatingthesocialrehabilitationofformerdrugaddictsthroughsport. A prevention campaign against cannabis ‘Drugs are uncool’ with the slogan ‘Your concentration. Your control.Yourlife.’,waslaunchedbytheLuxembourgishPoliceinOctober2013. 43 TheoriginaltextinFrenchis‘0%d’alcoolpendantlagrossesseetl’allaitement’ 44 Inthebeginningof1995,apilotprojectoncommunity-baseddrugpreventionhasbeenlaunchedbyCePT(seeEDDRA).Themain ideawastofocuspreventionactivitiesontheveryenvironmentanddailylifeexperiencesofyoungpeople.Variousdemandreductionactivitieshavebeenundertaken,eitherdevelopedbyCePT,SNJandseveralyouthcentres,orinitiatedbytherespectiveDistrict Councils.13districtcouncilsand150volunteersarecurrentlyinvolvedintheproject.Thefundingofthiscommunityprojectisjointly ensuredbytheinvolveddistrictcouncils,theEU(DrugPreventionProgramDG-V)andCePT. Theprimaryaimoftheprojectistoimprovecommunicationskillsondrugs,toincreaseparticipants’abilitiesinhandlingconflicts, stress and frustration (age range: 12 to 65 years) and to set up autonomous groups to continue implementing local prevention measures.Ineachparticipatingmunicipality,preventiongroupswerecomposedoflocalvolunteerswhowereaskedtoorganiselocal drug-preventionactivitiesrelatedtotheirspecificneeds.Cornerstoneconceptsoftheprojectareasfollows:-Multidisciplinarydrug prevention,-Tailor-madecommunitysolutions,-Healthpromotionwithregardtoriskandprotectivefactors,-Holisticandsystemic approach,-Targetgroupsoriented,-Routineevaluation. Thecommunity-basedpreventionnetworkisanongoingproject,whichisexpectedtodevelopitsproperdynamicoverthetime.The ideawastoswitchfromacentrallycoordinatedpilotprojecttoroutineandautonomouslocalprograms. 69 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Moreover,duringthesameperiod(i.e.October2013),thePolicelaunchedanothertwo-yearanti-Cannabis campaign.Thiscampaignaimedatcommunicatingwithalargerpublic,includingfamilies,youngstersand socio-educativesectors.Tothisend,aTV-andCinema-spotwasbroadcastedatthenationalTVchains,on theradio,thewebandatthecinema. In 2014, the Police hosted a conference on drugs for parents. This conference was organised by a local associationforparentsofschoolchildren(APEH45). Thecampaign“Doyouleaveordoyoustay?”(Geesdeodersteesde?)isaninitiativefromalocalyouth club(Hesperange).Itisthefirsteditionofanartcompetition,whereyoungstersbetween12and26years conceptualiseanawarenesscampaign,whichaddressedtherisksofcannabis.Thecampaignaimedtofoster dialogueandfreeexpressionforyoungstersonthesubjectofcannabis.Thegoalofthecampaignaimedat sensitisingandatdeconstructingfalseknowledgeoncannabis.Incollaborationwiththreeyouthclubsof Mamer,Kayl/TetingenandNordstadtthecampaignwaslaunchedonthe1stFebruary2014.Thecampaign wasassistedbytheCePT,SNJ,JDHand“IMPULS-Aideauxjeunesconsommateursdedrogues””(Solidarité Jeunesa.s.b.l.).Untilthe30thofJune2014youngstershadtimetocomeupwithaconstructivecampaign on the topic in terms of pictures, videos, music, dance, poems or visual arts. They could participate as anindividualorasagroup.Allsubmissionswillbeevaluatedandusedtoimprovetheeducationalwork togetherwiththepartners.Thegoalistolearnfromthegainedimpressions.Theorganisersexpectfromthe campaigntobetterunderstandyoungstersandtobetteradvisethemofthedangersandrisksofcannabis use. In2014,theStatec46hasconductedastudyontheoverallperceptionofthepresenceofdrugsinLuxembourg. Thisstudyrevealedthat35%ofthegeneralpopulationhavebeendirectlyorindirectlyinvolvedwithdrugs or drug resellers. In particular, 10% of residents are “frequently” in touch with drugs, or drug resellers, whereas12%“occasionally”,and13%“quiterarely”. In2014,athree-dayworkshoponriskbehaviorswasorganizedbyaLuxembourgishyouthclub(‘Jugendhaus Pétange’). In total, 213 high school students participated in this workshop, and were informed on the consequences of violence, sexually transmitted diseases, cannabis and alcohol intakes. The youth club indicatedthattheparticipantsdeclaredtobemoresensitizedtotherisksassociatedwithcannabisand alcoholabuseafterthisworkshop. SELECTIVE PREVENTION IN AT-RISK GROUPS AND SETTINGS At-risk groups In 2006, MDs without frontiers - Youth Solidarity (currently IMPULS - Aide aux jeunes consommateurs de drogues (Solidarité Jeunes a.s.b.l.), in collaboration with the Public Prosecutor’s Department of Youth ProtectionandtheJudicialPolice-DrugsUnit,launchedanewprojectcalledCHOICE,whichisbasedupon apilotprojectof‘earlyinterventionoffirstdrugoffenders’(FreD)initiatedbytheFederalMinistryofHealth andsocialsecurityofGermany.Thetargetgroupconsistsofyoungstersaged12to17whoenteredinconflict withdruglaw.TheoverallaimofCHOICEistoofferyoungstersanearlyandshort-terminterventioninorder 45 APEHisanabbreviationfor“Associationdesparentsd’élèvesdesécolesdelacommunedeHesperange”,andreferstotheassociation ofparentsandschoolchildrenfromtheHesperangecommunity 46 Statecisthenationalcentreforstatistics,http://www.statistiques.public.lu/en/actors/statec/index.html 70 In2012,«YouthSolidarity»elaboratedanewinterventionprogrammecalled“ProST–Programmeforselfresponsibledrinking”,aprogrammesimilartotheCHOICEprogramme,butspecificallydesignedfor alcohol misuse. In2014,thedepartmentwasrenamedinto:‘IMPULS-Aideauxjeunesconsommateursdedrogues(Solidarité Jeunesa.s.b.l.)’.Officialwebsiteformoreinformation(www.im-puls.lu). 2015 topreventfurtherdevelopmentofdrugabuseanddrugaddiction.An‘in-take’interviewallowsassessing whether a participation in the CHOICE project or an individual psychological follow up is indicated. A CHOICEgroupconsistsoffourinteractivesessions(6to8participants)whichprovideinformationondrugs, legislationandtreatmentservices,promoteauto-reflexion,reinforcementofpersonnelskillsandmotivation tochangeattitudestowardsdrugs.Inafirstphase,theprojectisregionallylimitedtothejudicialdistrictof LuxembourgCity.PoliceofficershandoutCHOICEflyerstoyoungstersinbreachwithdruglawincluding allinformationontheinterventionandinformthePublicProsecutor’sdepartmentofYouthProtection.The youngstersandeventuallytheirparentscontacttheCHOICEteamwithintwoweeksandthelatterinform thePublicProsecutorontheparticipationlevel.Acertificatetestifiestheparticipationoftheyoungster. In2009,HIVberodungCroix-Rouge,incollaborationwiththeMinistryofHealthandtheCHL,launched aprojectcalled‘DIMPS’(Interventionmobileforthepromotionofsexualhealth)intheframeworkofthe nationalactionplanonHIVandAids2006-2010.DIMPSismeanttoinformonriskbehaviourandprovide freeandrapidinfectiousdiseasetestingindifficult-to-accesspopulations.Amongotherinterventions,rapid testsforHIVandHCVandHBVareproposed.CurrentlytheDIMPSvanvisitslowthresholddrugagencies, gaymeetingplaces,redlightspotsandasylumseekersfacilities.Theirservicesarefreeofcharge47,andcan bebookedontheirwebsite(www.dimps.lu). From 2010 to 2013, the CePT participated in an EU project called ‘Promotion of social and personal competences in socially unprivileged persons’–PROSKILLS2intheframeworkoftheGrundtvig-Programme, thataimedtodevelopandtotestatrain-the-trainerconceptwithalotofdidacticmaterialformultipliers workinginthefieldofthepromotionofsocialandpersonalcompetences,jointlywithnineinstitutionsfrom eightEuropeancountries:Germany,Finland,Greece,Italy,Slovenia,Hungary,SwitzerlandandLuxembourg. In2012,theCePTorganizedaEuropeanworkshopinLuxembourgforallprojectpartnersandalsoanational pilot training with different domestic institutions. The project generated an extensive train-the-trainer conceptandatoolboxwithexercisesindifferentlanguages.Allmaterialisavailablefordownloadunder www.pro-skills.eu. Finally,atargetedsurvey‘Young people and drugs’ (Eurobarometer,no401)wasconductedfortheEuropean Commission,fromthe3dto23dofJune2014.Telephoneinterviewswereconductedineachofthe28EU countries.Eachnationalsamplewasrepresentativeofthegeneralpopulationbetween15and24years. Samplesizevariedbetween200and500respondents.Themainresultsarebrieflypresentedhereinafter: ° Information on illicit drugs and drug use - Potential sources of information Likewise results from the previous 2008 and 2011 Flash Eurobarometer studies, the internet was the mostpopularsourceofinformation,with59%(EU)(LU:49%)of15-24year-olds,whosaidtheywoulduse theInternetwhenlookingforgeneralinformationaboutillicitdrugsanddruguse.Thesecondpreferred source were friends (EU: 36%; LU: 29%) and on third position, a doctor, nurse or another health professional(EU:31%;LU:34%).IntheLuxembourgishsample,theinternetwasaswellthefirstchoice forinformationsourceondrugs,followedbydoctor,nurseorotherhealthprofessionalinthesecondplace andparentsorrelativesinthethirdplace(32%). 47 http://www.croix-rouge.lu/en/andhttp://www.dimps.lu/ 71 è Fig 3.1 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Potential sources of information about illicit drugs and drug use EU28 Luxembourg Telephone helpline Social or youth worker Someone at school or work Media Police Specialised drug counsellor or drug centre Parents or relatives Doctor, nurse,... Friend Internet 0 10 20 30 40 50 60 70 Source: Eurobarometer401 Information channels reaching youngsters in the past year Whenaskedthroughwhichinformationchannelsyoungpeoplehadbeeninformedontheeffectsandrisks ofillicitdruguseduringthepastyear,37%ofrespondentsreferredtothe internet (LU:41%),compared to 33% who reported media campaigns (LU: 40%) and 32% who mentioned school prevention programmes (LU:52%). Twenty-one percent said they had discussed these issues with friends (LU: 25%) in the past year, and almostasixth(14%)ofrespondentshadbeeninformedbytheirparents or other relatives (LU:19%).A minorityofrespondentssaidtheyhavebeeninformedoneffectsandrisksofdruguseby police (EU:9%; LU:19%)orviadrug and/or alcohol helpline (EU:1%;LU:1%).Finally,16%ofrespondentsreported not to have been informed at all (LU:5%) abouttheeffectsandrisksofillicitdruguseinthe12months priortothesurvey. In the two surveys, conducted in 2008 and 2011, the most frequently mentioned information channel wasmediacampaigns,followedbyschoolpreventionprogrammesandtheinternet.In2014,however,the orderchangedandinternetwasthemostfrequentlymentionedinformationchannel,followedbymedia campaignsandschoolpreventionprogrammes.Mostpopularinformationchannelsfortheyoungstersin Luxembourgare:schoolpreventionprogrammes,followedbytheinternetandmediacampaigns. 72 Information channels used in the past year to be informed about the effects and risks of illicit drugs Luxembourg EU28 2015 Fig 3.2 A have not been informed at all Drug and/ or alcohol telephone helpline Police Parents or relatives Friends Internet School prevention programme Media campaigns 0 10 20 30 40 50 60 Source: Eurobarometer401 How should drug problems be tackled? Asinthe2011FlashEurobarometer,thelargestproportionofrespondentsconsideredthatpublicauthorities shouldtackleproblemsonthesupplyside:57%mentionedtough measures against drug dealers and traffickers (LU:62%) asoneofthemosteffectivewaystoreducedrugproblems. As far as drug demand reduction is concerned, young people thought that other measures, such as preventionortreatmentandrehabilitationofdrugusers,wouldbemoreeffectivethanrepressivemeasures. 43%ofrespondentsreferredtoinformation and prevention campaigns (LU:39%) asoneofthemost effectivewaysofreducingdrugproblems;theleisure opportunities followed,with36%(LU:44%)of respondents choosing this as an effective measure and treatment and rehabilitation with 33% (LU: 27%).Bycomparison,tough measures against drug users wereconsideredtobeavaluablewayof dealingwithdrugproblemsbyaquarterofrespondents(EU:25%:LU:27%). Reducing one of the possible primary causes of drug abuse – i.e. poverty and unemployment – was mentionedby22%(LU:24%)ofinterviewees.Asin2011,legalisation of drugs wasthoughttobethe leasteffectivewayoffightingdrugproblems:18%(LU:19%)ofyoungpeople,however,putforwardthis measureasoneofthemosteffectiveones. 73 è Fig. 3.3 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition How should society’s drug problems be tackled? Luxembourg EU28 Making drugs legal More leisure opportunities Reduction of poverty and unemployment Tough measures against drug users Treatment and rehabilitation of drug users Information and prevention campaigns Tough measures against drug dealers and traffickers 0 10 20 30 40 50 60 70 Source: Eurobarometer401 At-risk families Since2003,theYouth-andDrughelpfoundation(JDH)isrunningaparentalprojectwiththeaimtoprovide psycho-social aid to drug-dependant parents and their children. The primary objective of the project is to ensure security and well-being to children and to strengthen parents’ educative capacities. This long term project is based upon contractual commitments, co-intervention, home visits and functions in close collaboration with involved services. An essential part of the project is outreach work. Meetings and interviewsareheldwithinthenaturalenvironmentofthefamily(athome). MoreovertheCePT,incollaborationwithJDHorganizedtrainingcoursesfordrug-dependantmothersin 2011 in order to build up their capacities as parent and improve mother-child relationship. (Project: O Mamm O Kanner, whichwasrenamed “1,2,3, lass!” “1,2,3,go!” in2009.)In2012theCePTfinalized thetrain-the-trainerhandbookfortheparentalprojectofJDHdescribingthetopicsandthemethodsofthe courses.In2013,preparationworkfornewsessionsofthetrainingcoursestookplaceinordertoadaptthe contentstotheneedsofthistargetgroup.Itsnexteditionisplannedfor2015. Recreational settings Youngsterdospendanimportantshareoftheirtimeinleisure,recreationalorsocialactivitiesandnumerous programmesinrecreationalsettingstakeplaceatthecommunitylevel,churchandyouthorganisationsor sport-orientedclubs.Thelatterarenotnecessarilydrugspecificandassuchdifficulttolistexhaustively. Since its creation in 1995 the CePT has initiated projects in the field of active leisure organisation: art performances, theatre, media supports (films, cartoons, etc.), seminars, ambulatory exhibitions, travel experiences,outdoor-andadventureeducationapproach,etc…TheCePTincreasinglyensuresthenational coordinationofsuchactivitiesintegratingtheaddictionpreventiontopicasoneofthevariouscomponents ofHealth education.Thelatterapproachisbelievedtohavemoreimpactonyoungsters(usersandnonusers) than a drug-centred approach. Indeed, human interactions in daily life situations as for instance 74 Inthisrespect,thedemandreductionactivitiesorganisedbythe‘MondorfGroup’(jointinitiativesofborder regions of France, Germany, Belgium and Luxembourg) jointly with the CePT and SNJ combine a nondrug-centred approachwithintercultural componentsinorganisingcorporateleisureactivitiesfor youngstersfrombordercountriesbasedontheconceptof‘adventure pedagogy’.Theannual‘adventure weeks48’dofitinabroaderprogrammenamed‘Adventurepedagogyandprimaryaddictionprevention’. With prevention concepts of adventure and nature pedagogy or cultural approaches such as theatre pedagogyandmusicorarteducation,theactivitiesprimarilyaimtoprovidetheopportunitytoyoungsters to experience group dynamics, conflict management, limit and risk assessment as well as the feeling of solidarity within a group of socially and culturally different people. The programme further aims at the reductionofriskfactorsandtheenhancementofprotectionfactors,byfocussingonyoungstersandtheir environment,ratherthanondrugsandaddiction.Regionalteamsspecialisedindrugpreventionmeetin autonomousworkingandtraininggroupsandreportactivitiestotheMondorfGroup. 2015 adventureorsportsactivitiesaremostadequateasaconceptualframeworkfortheprogressiveintegration ofdrug-relatedpreventioninitiatives. In2014,theMondorfGrouphasimplementedseveraltrainingsintheGreaterRegion,andtwoinLuxembourg. Thetargetaudienceweresocio-educativeprofessionals. Assuch,theypresentedmethodsofworkingwithanimalsandwithnatureawarenessandhowtousethemin thefieldofaddictionpreventionwork.(Formoreinformationhttp://cept.lu/projets/mondorfer-gruppe/). Currentlythereexistsnogenuinelegal frameworkregulatingpreventionandharmreductioninterventions in recreational settings such as on site information providing or pill testing. Discussions and a related parliamentarymotionduringtheamendmentprocessofthenationaldruglegislation(amendedin2001) did not bring up a final decision on the matter. Prevention material and info flyers on party drugs are providedtobarsandnightlifeestablishmentsbytheinitiativeofCePTorondemand.Thereremainshowever anobviouslackofinterventionsinthereferredsettings. Since May 2008, the CePT is an active member of several projects on the topic of health promotion andharmreductioninnightlifesettings,as‘Democracy,CitiesandDrugsII’,the‘ClubHealth–Healthy and Safer Nightlife of Youth’ (http://club-health.eu) project, or the ‘Nightlife Empowerment and Well-being Implementation Project’ (NEWIP – http://www.safernightlife.org/). The main objectives of these networks and projects are to improve existing interventions reducing drugs related harm in nightlife and party settings and to facilitate their transferability, evaluation and implementation. In the NEWIP project, the CePT co-authored in 2013 guidelines on good practice standards when developing peer projects in nightlife settings (Noijen, J., Duscherer, K., Schrooten, J., et al., 2013, available at http://www.safernightlife.org/pdfs/standards/NEWIP_P_standards-final_20.12-A4.pdf). InthecontextofhispartnershipwiththeprojectNEWIP,organizerofthe‘EuropeanPartyfriendsnight‘,the CePTparticipatedthe24thNovember2012inthisEuropeaneventandinparticularlyintheaction‘party friendstip‘,whichprovidesadviceontakingcareoffriendswhilecelebrating,andthisundertheslogan ‘Keepaneyeonyourfriends‘. In2012,thesamenetworkorganizedthefirstNIGHTS2013conferenceinPadova,Italy,withtheaimto improve the quality of the nightlife scene and the wellbeing party goers. The event addressed nightlife stakeholderssuchashealthprofessionals,volunteers,club/partyorganizers,publicbodyrepresentatives, scientists,scholarsandpartygoersbyofferingthemmultiplegatheringmodalitiesthatfitdifferenttopics andtypeofexpertise,includingworkshops,talks,showcases,multimediapresentationandroundtables.The fullprogrammeofthiseventisavailableathttp://www.nights2013.eu. In2014,theNIGHTS 2014conferencewasheldinParis,andLuxembourgwasrepresentedbytheCePT. 48 See EDDRA 75 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 In 2013, the CePT joined the NEW-Net (Nightlife, Empowerment & Well-being Network). NEW-Net is a Europeannetworkofcommunity-basedNGOsactinginthefieldsofhealthpromotionandnightlife. Asthenightlifesettingprovidesaprivilegedenvironmentforrecreationaldrugsuse,theCePTlaunchedthe projectPartyMAG-NetundertheINTERREGIVAProgramme:GreatRegion2007-2013,Project52GR3 3100(www.mag-net.eu)aharmreductionprojecttargetedatrecreationaldrugusersinthepartysceneof LuxembourgandthesurroundingGreaterRegion.Thereferredprojectincludesthecreationofanetworkof expertsfromGermany,France,BelgiumandLuxembourgaimingtodeveloppreventivemeasuresforschool, recreationalandsocialsettings.ThedurationoftheprojectcoversJune2009toMay2012.Intheframework oftheMAG-Netproject,adirectoryofallthecounselingandhelpservicesrelatedtodrugsandaddictions waspublishedfortheGreaterRegion. PartyMAG-Net’sboothsarepartofmostnationalmusicfestivalssince2011.Theseinterventionsintheparty scenefocusonkeepinginlinewiththepartyspiritofthetargetedeventswhileadequatelymanagingrisky situations.Besidesinformationonpsychotropicsubstances,therecreationalMag-Netpointofpresencealso providesearplugsandinformationonauditoryrisks,aswellascondomswithandwithoutlubricant,breath tests,butalsodisinfectingsoap,sunscreenanddrinkingwater.Thepubliccanfindtimeschedulesofpublic transportsorcontactdetailsofthefacilitiesavailableintheregion.Themainfocusisoninformationandis providedinsitubyateamoftrainedpeers.Trilingualpostcardsaremadeavailabletothepublic,including informationonalcohol,cocaine,cannabis,syntheticcannabinoids,tobacco,XTC,LSD,ketamine,GHB/GBL, heroine,speedandinformationonroadsafetyandriskysexualbehavioursinrelationtodruguse. In2014,thepartyMAG-Netstandwaspresentat16festivalsandeventsinLuxembourg,withmorethan 60,000visitors. Toevaluatewhethertheirservicesneedtobereconsidered,andchanged,CePTconductedasmallsurvey study at the Party MAG-Net stand. Accordingly, they assessed the age, gender, transportation means, languageskills,andtheconsumptionof10legalandillicitdrugs,withinasampleof3679participants (53.8%females).Theirmeanagewas22.6years(females=22yearsold;males=23.4yearsold). The results from this study indicated that the majority of the participants drive home by car (42.8%), followedbythosewhosleepinatentaftertheevent(29.1%),travelbybusortrain(13.8%),orco-drivewith theirpeers(11.6%).Aminorityoptsforataxi(1.6%),ortosleepatahotelorahostel(0.9%). Themostprominentdrugswerealcohol(89.9%)andtobacco(49.6%),followedbycannabis(32%),ecstasy (4.9%),cocaine(4.7%),speedandamphetamines(3.3%).Lessthan2%ofthesampledeclaredtoconsume “otherdrugs”,suchasmushrooms,LSDorheroine. InadditiontothepartyMAG-Net,theCePTinclosecollaborationwiththeMinistryofHealth,thePublic Prosecutors’OfficeandtheNationalLaboratoryofHealth(LNS)haslaunchedin2014apilotprojetnamed ‘DUCK’(DrUgCheCKing)(CePT,2014).The‘DUCK’serviceonsitedrugtestinginfestivesettings.‘DUCK’ servicesareprovidedatthePartyMAG-Netstand,atfestiveareas.In2014,the‘DUCK’teamwaspresentat 12events.Intotal,53samplesofdrugswerecollectedforanalysesonthechemicalcompositionofdrugs. Finally,theParty+isaprojectdedicatedtothedevelopmentofsaferpartylabelsinanetworkofEuropean cities49.InLuxembourg,theCePT’sproject“PartyMAG-Net”iscurrentlybecomingqualifiedforasaferparty label. 49 TheParty+websitehttp://www.partyplus.eu/ 76 Geographic Residence 6% 2.1% 4.2% Luxembourg: 72,4% Germany: 15,3% 15.3% France: 4,2% Belgium: 6,0% 2015 Fig. 3.4: Other: 2,1% 72.4% Source: CePT2015 Fig. 3.5 Substances consumed during the last 2 weeks 100 89.9 80 60 40 49.6 32.0 20 0 4.9 4.7 3.3 1.8 1.6 1.5 0.7 0.6 Source:CePT2015 Thecampaign“KeenAlkoholënner16Joer–Mirhaleneisdrun”(“Noalcoholunder16years–Westick toit!”),incollaborationwiththeMinistryofHealthstartedin2007foremostincommunitysettingsand wasre-launchedwithapressconferenceinJune2011.Thiscampaignfocusedtheadultpopulationand thepromotionoftheirresponsibility.Thefocuswaslaidontheresponsibilityofthevendorsofalcoholic drinks and the prohibition of selling alcohol to minors under 16 years. In 2011, the CePT appealed to the responsibility of the adults on the verge of the summer festivities and especially the festivity of the national holiday. The message was spread by the media and transported by several materials and a lot of collaborating partners. The campaign has continued his course consistently down to the present. The scientificevaluationofpartsofthiscampaignespeciallyin4communitieswasrealizedbytheUniversityof LuxembourgintheframeworkoftheresearchprojectSORES(“Socialresponsibilityasastrategicconceptof preventionwork”,2009-2012).TheresultswerepublishedandpresentedbytheUniversityofLuxembourg on the 11th December 2012 as a document called “Local network creation as strategic concept in the prevention–Evaluationofanawarenesscampaigntothealcoholconsumptioninadolescence”.TheMinister ofHealthandrepresentativesofdifferentministries,experts,policemembersandmembersofassociations acting in the field of alcohol prevention participated in this presentation. The study addressed topics of 77 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 socialresponsibility,networkstrategyandintergenerationalbehaviour.Amajorobjectiveofthecampaign wastoreachadultsasmultiplicatorstopromotehealthandindividualresponsibilityamongchildrenand youngsters. Results show that, concerning the intergenerational behaviour, youngsters expect model behaviour and responsibilityadoptionfromtheadultgeneration.Overall,theresearchresultsconfirmtheeffectivenessof thepreventioncampaignwithregardtothenetworkstrategyandthemultiplicators.Theconclusionsofthe evaluationwillbeimportantforthedevelopmentoffuturepreventioncampaigns. Withthe“EuropeanActiononDrugs”theEuropeanUnionwantstoapproachagrowingproblem,concerning the whole European society, in a determined, balanced and coordinated manner. For this purpose a charterwascreated,signedbynationalandlocalpublicauthorities,schools,publicservices,consortiaor organisations of any size. In Luxembourg, the European action plan is coordinated by the “Responsible YoungDrivers”.Interventionsdonotonlyaddressyouth,butalsopeopleatriskofdependence,ofallage categories. Occupational settings IncooperationwiththehumanresourcesdepartmentoftheCityofLuxembourg,theCePThasrunapilot project to prevent addiction behaviour and its consequences in City employees based on a preliminary situationandneedsassessment. Thehealthserviceatmulti-sectorialwork(STM:ServicedeSantéauTravailMultisectoriel)isprovidinga toolboxtohelpcompanieswillingtoimprovepreventionofalcoholanddrugconsumptionatwork.This toolbox includes tools for the 3 prevention areas: primary, secondary and tertiary. Currently only the documentsfortheprimarypreventionareavailable.Thesupporttoolsfortheprimarypreventiondeveloped bytheSTMareinformationleafletsforcompaniesandemployeesaswellaspostersallowingthecompanies tointroducepreventioncampaigns.Theleafletscontaingeneralinformationonthepsychoactivesubstance (alcohol, drugs and medicaments), self-evaluation or questions for reflection, recommendations from the accidentassuranceaswellasusefuladdressestogethelp. In 2014, a conference ‘Alcohol and drugs at work’50, was organized with the help of the Luxembourgish Chamber of commerce, the Chamber of Trade and a supportive institution for enterprises (i.e. ‘Guichet UniquePME’).Alcoholrelatedpoliciesatwork,andhowtoadresstheminaworkcontract,werediscussed. INDICATED PREVENTION Children at risk with individually attributable risk factors Threebasicmechanismsareinplaceinordertopreventtheonsetofproblemdruguserelatedtobehavioural problemsincludingforinstanceADHD.Outpatientpsychiatriccarebytrainedpsychiatristorbyspecialist consultation centres is a first option. In more severe cases the national juvenile psychiatric service may providein-patientcare.MorespecificallytargetingdrugusetheparentalityserviceofJDHisaimingtoassist drugdependantparentstotakecareoftheirchildrenandtobuildupcapacitieshelpingthemtodealwith potentialrelatedproblems. 50 TheoriginaltitleinFrenchis‘Alcooletdroguessurlelieudetravail’ 78 NATIONAL AND LOCAL MEDIA CAMPAIGNS AspecialdepartmentoftheCePT,called“FroNo”(“Check It”),offerssinceSeptember2007aphoneline (+35249777755,accessibleeveryworkingdayfrom9:00a.m.to1:00p.m.)aswellasanonlineservice ([email protected]).TheFroNodepartmentcanbecontactedconcerningallmattersrelatedtodrugs,addictions andpreventionwork.FroNoprovidesonlyinformationandisnotadrug-advicecenter. Fig. 3.6: 2015 A special CD-Rom has been developed by the Ministry of Education providing information on ADHD to schoolsandtoparents.TeachersarealsotrainedtorecogniseADHDsymptomsandtoreactadequately. Number of drug-related questions coming in through the Fro No lines (phone and email) in 2014 50 31,6 25 24,3 12,5 3,6 2,2 2,2 0 Source: CePT,2015 In total, the Fro No” service was solicited at 203 times, against 136 times in 2013. The most frequent questionswererelatedtocannabisandalcoholabuse. Furthermore,aseriesofleafletsondrugs(i.e.alcohol,cannabis,cocaine,ecstasy,heroin,magicmushrooms, tobaccoandonhypnoticsandanxiolytics),informingthegeneralpublicontheeffects,legalissuesandrisks werediffusedtoabroadnationalpublicbeingdispatchedthroughcounselingservices,MDs(i.e.general practitioners,neurologists,psychiatrists)andsecondaryschools.TheseleafletsareavailableinFrenchand Germansince2009andareeditedsinceSeptember2011alsoinEnglishandPortuguese.Alltheleaflets andalargecollectionofspecializedliteratureondrugs,addictionsandaddictionpreventionareavailableat theCePTorfordownloadat:http://cept.lu/fr/frono. In2013,theleafletsoncannabisaswellasonhypnoticsandanxiolyticshavebeenreedited.Theyhavebeen releasedinGerman/FrenchandEnglish/Portuguese.Atthesametime,leafletsonalcoholandtobaccohave beenreleasedin4languages.Allinall,14,700leafletsondrugshavebeendistributedin2014. 79 è Fig. 3.7 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Number of dispatched leaflets on drugs and psychotropic medications in 2013 3000 2703 2408 1920 2000 1897 1713 1131 1000 1046 741 635 so lv en ts to ba cc o s us hr oo m m ec st as y ag ic m he ro in ca nn ab is co ca in e al co ho l hy p an not xi ics ol yt an ic d s 0 Source: CePT,2014 Additionally,theFroNodepartmenteditstwodirectorieslistingallthecounselingandhelpservicesrelated todrugsandaddictions(Les services spécialisés dans le domaine des drogues et toxicomanies au Luxembourg) andtochildhood,youthandparents(Les services de consultation pour enfants, jeunes et leurs parents).These directorieswereupdatedandre-publishedin2012.AllthisinformationisalsoavailablethroughtheCePT homepagehttp://cept.lu/,whichfacilitatestheaccesstoabroaderpublic. In2013,2,192directorieslistingallthecounselingandhelpserviceshavebeendistributed. A flyer on solvent/inhalant misuse was exclusively addressed to adults taking care of children and adolescents.Arapidassessmentsurveywithindifferentprofessionalgroupsconductedbyanewlycreated department of CePT (2009) (m.e.s.h. http://cept.lu/fr/cept/65-articles-cept/540-enquete-sur-labus-desolvants)providedabetterinsightinthisphenomenoninLuxembourg. InJune2009,CePTlaunchedanewawarenessraisingcampaignonwhatdependencyactuallyisabout. Withoutfurtherexplanation,yoyoswiththeinscription‘I make dependent’,thephonenumberandthee-mail addressofthenationalpreventioncentreweredistributednexttothecentralrailwaystationandinthe pedestrianareaofLuxembourgCity.Additionally,newspaperarticleswithprovocativequestionsondifferent consumptionbehaviourswerepublished:Chocolatemakesdependent?Cannabismakesdependent?Mobile phonesmakedependent?Alcoholmakesdependent?Yoyosmakedependent?Themainobjectiveofthis campaignwastotackleinterestofthegeneralpublic,tomotivatepeopletoaskquestionsandtounderstand theversatilityoftheconceptofaddiction. 80 INTRODUCTION Atthenationallevel‘problemdruguse’(PDU)or‘harmfuluse’isdefinedaccordingtotheWHOLexiconof AlcoholandDrugterms(Geneva,1994):‘A pattern of psychoactive substance use that is causing damage to health, physical or mental. Harmful use commonly, but not invariably, has adverse social consequences […]’. IncontrasttotheEMCDDAdefinition,themodeofadministration(injection)isnotaselectivecriterionin thenationaldefinitionalthoughtypesofsubstancesinvolvedareidentical.Regular/longdurationuseof heroinviainhalationisthusincluded.Accordingtothenationaldefinition,problemdruguseisassociated toahighprobabilityofinterventionortheneedofinvolvementofathirdpartyfromthelawenforcement orcaresectors.ThisapproachisconsistentwiththefactthatPDUsurveillancesystemsinLuxembourgare basedontheinstitutionalcontactindicatorandnotexclusivelyonthetreatmentdemandindicator. 2015 4. PROBLEM DRUG USE Data on PDU in this chapter originate from the national drug monitoring system RELIS developed and maintained by the national EMCDDA focal point. The RELIS network includes specialised drug agencies (100%coverage),lawenforcementagencies,nationalprisonsandsince2009,psychiatricdepartmentsof generalhospitalsnationwide. Accordingtothelatestserialandmulti-methodsprevalencestudy(Origer,201251)performedon2009data, national prevalence of PDU situates at 2,070 persons (C.I. (95%): 1,553 to 2,623). A decreasing trend inPDUprevalencehasbeenobservedfrom2003onwards.Asimilarevolutionoccurredalsoforproblem heroinuse(2007:1,900PDU:5,90/1000).Theprevalencerateofintravenousdruguse(IDU)inthenational populationaged15to64yearshasstabilisedduringthesameperiod.AlmostallindirectPDUprevalence indicatorsreflecttrendsdocumentedbyin-depthPDUstudies. Intravenousheroinuseassociatedtopoly-drugusehasbeenreportedasthemostcommonconsumepattern inPDU.Lowqualitycocaineuseincombinationwithheroincontinuestobeobserved.Ecstasy-likesubstances andATSarestillpopulareventhoughseizurefiguresdosuggestaninversetrend.Methamphetamineuse inLuxembourgisverylimitedbutATSseizureshaveincreasedforthepastyears.Noevidenceexiststhus far on the presence of crack (although freebasing has been reported sporadically by field agencies) or desomorphine on the national market. The use of most ‘new synthetic/emerging substances’52 recently detected in other EU Member States has not been reported thus far with the exception of mephedrone and4-MAseizedin2010andmethyloneseizedin2012.Cannabisuseofclientsincontactwithservices (institutionalcontactindicator)havebeenontheincreaseforthelast5consecutiveyears.Also,cannabis showinghighTHCconcentrationsisincreasinglyfoundonthenationalmarket. 51 Origer A.PrevalenceofProblemDrugUseandInjectingDrugUseinLuxembourg:ALongitudinalandMethodologicalPerspective.Eur Addict Res.2012;18:288-296. 52 SubstancessuchasMBDB,4-MTA,Ketamin,PMMA2C-I,2C-T-2,2C-T-7,2C-D,2C-E,TMA-2,BZP,TFMPP,5-MeO-DIPT, 5-MeO-DMT,AMT,ALEPH7,DXM,DPT. 81 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition PREVALENCE AND INCIDENCE ESTIMATES OF PDU National prevalence data DatapresentedinthepresentchapterhavebeenprovidedbyserialdrugprevalencestudiesonPDUagedbetween15and64yearsperformedon1997,1999,2000,2003,2007and2009data(Origer,2001,2012)53. Thelateststudy,publishedin2012,wasperformedon2009dataandallowedtoassesstheevolutionof PDUprevalenceoverthelastdecade,bymeansofcomparablemethodologiesanddatasources. TheresearchstrategyreliedonthemethodologicalframeworkoftheLuxembourgishInformationSystem onDrugsandDrugAddiction(RELIS),setupin1995bythenationalfocalpointoftheEMCDDA.RELIS standsforanationwidemultisectorialinformationnetworkandwasbuiltuponthemethodologicalassumption that data exclusively from drug treatment settings may not provide an accurate picture of problem druguseasthesenotablyexcludeout-of-treatmentuserswhosedrugusehasgeneratedconflictswithlaw enforcementonly.Hence,toapproachthegenuineheterogeneityofthedrugmisusephenomenon,RELIS routinelycompilesdatafromallexistingspecialisedin-andout-oftreatmentsources,in-andoutpatient servicesources,lowthresholdagencies,psychiatricdepartmentsofgeneralhospitals,substitutiontreatment programme,prison,andlawenforcementagenciesAlso,RELISreliesonthe‘institutionalcontactindicator’, asanalternativetothemorecommonlyused‘treatmentdemandindicator’.Assuch,itprovidesforthemost comprehensiveandreliabledataonproblemdrugusersindexedbynationalinstitutions. IncompliancewithRELIScasedefinitions,thepresentstudyspecificallyaimsattheprevalenceestimation ofproblemuseofillicitlyacquiredhighriskdrugs(HRC)inthenationalpopulationaged15to65years. Thefollowingmethodshavebeenapplied:Casefinding(CF),capture-recaptureon2,3and4sources(CR 2,3,4),truncatedPoissonmodelassociatedtoZelterman’sandChao’sestimators(tPm),andfourdifferent multipliermethodsusingdatafromlawenforcementsources,drugmortalityregisters(D1,2,3)andtreatment agencies(T) Fig. 4.1: Absolute prevalence estimates of problem drug use and injecting drug use – Grand Duchy of Luxembourg (1997 – 2009) 3000 2500 2000 2,350 2,530 2,625 2,470 2,100 2,173 1,765 1,757 2,070 1,907 1,745 1500 1,656 1000 1997 1998 1999 2000 2002 2003 2004 2005 2006 2007 CR2 CR3 (1) CR3 (2) CR4 M1 M2 M3 M4 MtP Zelterm. MtP Chao P(IDU/PDU) M(IDU/HIV) Mean PDU prevalence Mean IDU prevalence Source:Origer,2012 82 2001 53 Downloadableathttp://www.relis.lu 2008 2009 Source:Origer,2012 2015 CR2 / CR3 / CR4:capture-recapturemethodson2,3and4sources. M1:multipliermethod;policeanddrug-relateddeathsregisters. M2:multipliermethod:numberofdruglawoffenders/lawenforcementcontactrateofdrugoffenders. M3:multipliermethod;numberoffataloverdosecases/drugrelatedmortalityrate. M4:extrapolationfromtreatmentdata. P(IDU/PDU):multipliermethod;PDUestimates/IDUrates. M(IDU/HIV):multipliermethod;numberofHIVinfectedIDU/rateofHIVinfectionsamongIDU. Table 4.1: Abs olute prevalence and prevalence rates according to selected sub-groups – Grand-Duchy of Luxembourg (1997 – 2009) 1997 1999 2000 2003 2007 2009 GENERAL POPULATION Nationalpopulation on1stJanuary 418,300 429,200 435,700 448,300 476,200 493,500 Nationalpopulationaged between15and64years on1stJanuary 281,100 287,100 291,000 300,800 322,000 336,015 PROBLEM DRUG USERS (PDU) 2,100 2,350 2,625 2,530 2,470 2,070 1,900–2,300 1,994–2,758 2,246–3,295 2,144–3,293 1,945–3,343 1,553–2,623 5/1000 5.48/1000 6.02/1000 5.64/1000 5.19/1000 4.19/1000 Totalmeanprevalence rate-PDU-age:15-64 7.47/1000 8.19/1000 9.02/1000 8.41/1000 7.67/1000 6.16/1000 IDUmeanprevalence 1,656 1,757 1,765 1,745 2,173 1,907 PDUmeanprevalence MeanC.I.(95%) Totalmeanprevalencerate -PDU INJECTING DRUG USERS (IDU) Estimatemargins 1,528–1,785 1,686–1,828 1,610–1,920 1,735–1,755 1,924–2,422 1,524–2,301 Totalmeanprevalence rate-IDU 3.96/1000 4.09/1000 4.05/1000 3.89/1000 4.56/1000 3.86/1000 Totalmeanprevalence rate-IDU-age:15-64 5.89/1000 6.12/1000 6.07/1000 5.80/1000 6.75/1000 5.68/1000 Source:Origer,2012 83 è Fig. 4.2: 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition PDU prevalence rates according to selected sub-groups (1997 – 2009) per 1,000 inhabitants aged 15-64 years 10 9.02 9 8.41 8.19 8 7.67 7 7.47 6.75 6.12 6 6.07 6.02 5.89 5.68 5.64 5.48 5 6.16 5.8 5.19 5 4.19 4 1997 1998 1999 2000 2001 2002 2003 Prevalence rate: total population 2004 2005 2006 2007 2008 2009 Prevalence rate: pop. 15 - 64 years Prevalence rate: IDU 15 - 64 years Source:Origer,2012 Themid-pointestimationperformedon2009dataprovidesanabsoluteprevalenceofproblemHRCdrug users (PDU-HRC) of 2,070 persons (C.I. (95%): 1,553 to 2,623). In terms of prevalence rates estimates for thesameagecategories,6.16outof1,000habitantsagedbetween15and64yearsshowproblemdrug use. Accordingtoserialdataavailablefortheperiod1997to2009,absoluteprevalenceandprevalenceratesof PDU-HRC have been showing an increasing trend until 2000. After a short stabilisation phase, a decreasing trendhasbeenobservedfrom2003onwards. Absoluteprevalenceandprevalenceratesofintravenousdruguse(IDU)inthenationalpopulationaged15 to64yearshavebeenincreasingbetween1997and2007toshowfirstsignsofdeclinein2009. ThestabilizationandsubsequentdecreaseofnationalPDUprevalenceoccurredwithintheimplementation phaseofthefirstandsecondnationaldrugactionplans,havingstartedin1999.Theobservedtrendsare alsoconfirmedbymostofpertinentindirectindicatorsrelatedtodemandandsupplyreduction. INDIRECT INDICATORS OF PDU PREVALENCE TRENDS InordertovalidatePDUestimatesandfollowupprevalencetrendsbetweentwosuccessiveprevalencestudiesasetofindirectindicatorshavebeencompiledandanalysed. 84 Prevalence estimates (problem use of high risk drugs) and evolution of selected indirect indicators 2015 Fig. 4.3 OD Drug offenders (N) Syringes distribution Low threshold admissions/10 Prevalence 250 Substitution treatment Drug treatment demanders (intra-institutional multicounts incl.) 150 50 -50 1997 1999 2001 2003 2007 2009 2010 2011 2012 2013 2014 Source:RELIS,2015 Demandreductionindicatorsaremostlyconsistentwithsupplyreductiondata(seefig.4.3).Mostindirect PDUprevalenceindicatorsalsoreflecttrendsdocumentedbyin-depthPDUstudies. The number of fatal drug-related overdoses has peaked in 2007 and has been witnessing an obvious decrease since then. Likewise other EU Member States, the evolution of the referred indicator is known to show fairly important variations due to factors such as quality of available drugs, consume patterns, availabilityofharmreductionservices,etc.Moreover,theabsolutenumberoffataloverdoseshasreached a fairly low level compared to previous years. Changes in small figures may produce great variations in percentages.Comparisonofoverdoseratesovertheyearswouldprobablymakethedownwardtrendmore obvious,whichisinconcordancewithnationalprevalencefigures. Admissionstatistics inlowthresholddrugagenciesdependofcourseonthecapacitiesoflowthreshold offersandlevelofaccesstoharmreductionmeasuresatthenationallevel.Thissaideventhoughharm reductionoffershavebeenfurtherdevelopedinLuxembourg,thenumberofcontactswiththelattertendto decreaseifcomparedtoyear2010. Anewresearchprojecthasbeenlaunchedin2009ontheconsolidationandvalidationofPDUestimatesby indirectindicators.Acorrelationmatrixincluding18indirecttrendindicatorshasbeenconceivedtofollowuptrendsandstrengthofassociationbetweentheseindicatorsandbetweenPDU/IDUprevalencefigures andthelatter.Firstresultswillbeavailableinthecourseof2016. Local or regional prevalence studies Due to the specificity of the national drug scene and the geographical dimension of the country, local prevalencestudiesarenotconsideredbeingapriority. 85 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Characteristics of indexed PDU Relyingonamulti-sectorialdatanetworkincludingspecialisedin-andoutpatienttreatmentcentresand lowthresholdfacilities,generalhospitalsaswellaslawenforcementagenciesandnationalprisons,RELIS enablestheassessmentofnewtrendsinthe problem drug users populationingeneralaswellasindrug treatmentdemandersinparticular.NFPhasoptedforaholisticmonitoringofthedrugpopulation.ThefollowingdataareprovidedbyRELISthusreferringtoallHRCdrugusersindexedbythenationalspecialised treatmentandlawenforcementnetworkand,assuch,definedasproblemdrugusers. The number of PDU person-contacts indexed by national institutions in 2014 figured 5,806 (2002: 4,701)(inthisfiguredoublecountingisincludedmeaningthatagivenpersoncouldhavebeenindexed twiceandmorebydifferentinstitutions.Itisthusnotrepresentingtheactualprevalence,whichhastobe assessedbyothermethods). Moreprecisely,2,383usershavebeenindexedbynationalspecialiseddrugdemandreductionagenciesand 2,318druglawoffendersbysupplyreductionagenciesin2002.In2014thesameagencieshaveindexed 2,791and3,015personsrespectively. Table 4.2: Main characteristics of PDU indexed by the national drug monitoring system, RELIS (valid percentage) Gender Male Female Nationality Natives Non-natives - of which Portuguese French Others Mean age Male Female Total 86 2000 2004 2008 2009 2010 2011 2012 2013 2014 TREND 77% 23% 78% 22% 77% 23% 83% 17% 80% 20% 82% 18% 84% 16% 81% 19% 83% 17% 54% 46% 54% 46% 48% 52% 48% 52% 49% 51% 42% 58% 42% 58% 49% 51% 52% 48% 51% 17% 32% 58% 11% 31% 38% 28% 34% 49% 16% 35% 39% 23% 38% 34% 24% 42% 38% 17% 45% 35% 16% 49% 32% 11% 57% 32Y6M 31Y5M 32Y3M 50.2% 17.3% 32.5% 53.8% 19.9% 26.3% 29Y4M 31Y2M 31Y8M 31Y9M 32Y4M 33Y4M 33Y8M 33Y10M 26Y10M 28Y4M 28Y5M 28Y3M 28Y9M 30Y1M 30Y6M 32Y2M 28Y9M 30Y6M 30Y11M 31Y2M 31Y7M 32Y8M 33Y2M 33Y6M Primary drug Opiates Cocaine Others 84% 7% 9% 76% 16% 8% 72% 17% 11% 78% 9% 13% Polydrug use 87% 93% 89% 74% 80.6% 67.7% 55.8% 9.5% 18.1% 12.2% 9.9% 14.2% 32% 76% 67% 54% 47% 54% 49% 51% 50,3% 49,7% 3% 62% 5% 61% = Primary opiates administration mode Iv Non-iv 56% 44% 55% 45% 45% 55% 62% 38% 59% 41% 58% 42% 42% 58% Infectious diseases HIV HCV 4.3% 40% 4% 58% 4% 65% 5% 51% 6% 52% 4% 61% 4% 54% ThemeanageofindexedPDUevolvedfrom28yearsand4monthsin1995to32yearsand3monthsin 2014.MeanageofmalePDUhasbeenincreasingfasterthanforfemales.Inreferencetoyears2004to 2012,adiscontinuousdecreaseofminorsintheoverallPDUpopulationhasbeenobservedinpolicedata. Nevertheless,recentdatasuggestanewincreaseofminorsinPDU. Themeanageofnativeandnon-nativeproblemdruguserstendstobalance.Oneobservesanaverageaging ofthepopulationoflong-termdruginjectorsandasensitivedecreaseinagereferredto“new”PDU. 2015 The male/female ratio of the PDU population is stable at 4:1. During the last ten years the proportion of indexed non-native PDU has shown strong variations but a clearly increasing tendency since 2003. Thepopulationofnon-nativedruguserslargelyconsistsofPortuguesenationals,whoseproportionisnot consistentlylowerthantheoneobservedinthegeneralpopulation. Worth mentioning is also the overall, yet discontinuous increase of the average age of overdose victims duringthelasttwelveyears.PDUtendtocontactdrugtreatmentfacilitiesatanearlierstage,whichmaybe duetoamorediversifiedoffercurrentlyavailable. Intravenous heroin use associated to poly-drug use has been reported as the most common consume patterninPDU.Theproportionofpoly drug use(54%)hasbeendecliningafterarecordlevelin2004 (93%)andwasstilldecreasingin2011,2012and2013.In2014,ithasslightlyincreasedincomparisonto 2013.Incontrastto1995data,theswitch to intravenous drug useoccursearlierin2014.Theratioof intravenous opiatesconsumetothe inhalation modeis3:2in2014.Provisionof‘blowingparaphernalia’ (e.g.aluminiumfoils)byspecialiseddrugagenciesmayhaveinfluencedconsumepatterns.Theprevalence oftheuseofcocaineasprimarydrugshowsanincreasingtrendsince2000,buttendstostabilisein2009 and2010. Followingasensibleincreasein2011,theprevioustrendofcocainestabilisingasprimarydrugis confirmedby2014data.Ecstasy-likesubstancesandATSuseappearstobestablewhichhoweverdoesnot informonprevalenceingeneralpopulationasRELISdatarefertoPDUandnottotheoverallpopulationof recreationaldrugusers. Thenumberofpersonsincontactwiththenationalspecialisednetworkfor(preferential)cannabisusehas beenshowingagloballyincreasingtrend2014(25.5%). PDUshowfairlystableinfectionratesofHIV(5%)between2000and2014,whereastheHCVprevalence rate(61%)isfairlystablesince2004. Theresidential statusofindexedrespondentshasimprovedoverthelastyears.In1995,31%oftheusers reportedstableaccommodation;currentlythesameproportionsituates72%.Thisimprovementispartly duetovariousaccommodationandhousingoffersforaddictedpeoplesetupintheframeworkofthedrug actionplan. The unemployment rate (60%) tends to plateau. However, the proportion of professionally active respondentsreportingastablejobsituation(e.g.longtermcontract)hasbeenstablein2013and2014, whichshouldalsobeputinthecontextofthecurrenteconomiccrisis. 87 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 DATA ON PDU FROM NON-TREATMENT SOURCES DataonPDUfromnon-treatmentsourcesaremainlyprovidedbythenationalspecializeddrugunitofthe JudicialPolice.TheprofileoftheseusersissimilartoPDUfromtreatmentsettingsknowingthatthenational drugmonitoringsystemindexesbothsources. TheratioofmaleandfemalePDUisalmostidenticaltoPDUfromtreatmentsources(80.2%male,19.5% femaleoffendersvs.78.2%malesand21.8%femalesfromtreatmentsources).Theirmeanageis32.4years, womenbeingslightlyyoungerthanmen(32.5yearsformaleand31.8yearsforfemaleoffenders). 50%oftheoffendersarenatives.Likewise2012,mostnon-nativeswerePortuguesecitizens,followedby Belgiannativeoffenders. Mostoffenders83%(90%)arerecidivists(hadmorethanonedrug-relatedpolicerecordduringtheirlifetime).28%(13%)werearrestedfordrugdealing,72%(87%)arechargedwithillegaldrug.Drug-lawoffenders(beingsimultanouslyproblemdrugusers)aremostlyarrestedforheroinandcocaine.Amajorityare reportedpolydrugusers. 88 INTRODUCTION Drugtreatmentisthe‘useofspecificmedicaland/orpsychosocialtechniqueswiththegoalofreducingor abstainingfromillegaldruguseandtherebyimprovingthegeneralhealthoftheclient’.54 2015 5. DRUG-RELATED TREATMENT: TREATMENT DEMAND AND TREATMENT AVAILABILITY Specialised drug treatment infrastructures are relying on state financing and on ministerial control and qualityassurancemechanisms.Treatmentoffersaredecentralisedandmostcommonlyprovidedbystate accreditedNGOs. Forthepurposeofthepresentchapter,drugtreatmentisdividedinthefollowingcategories: - Outpatient treatment :thepatientreceivesdrugtreatmentwithoutstayingovernight,pharmaceutically assistedornot55; - Inpatient treatment :thepatientisstayingovernight,pharmaceuticallyassistedornot(including detoxification); - Opioid Substitution Treatment (OST) : a type of medical treatment provided to opiate addicts primarilybasedonthedeliveryofasimilaroridenticalsubstancetothedrugnormallyused.Substitution treatment may be accompanied by psycho-social care. OST may be provided in in- and outpatient settings. Drugtreatmentismonitoredandqualityassuranceoccursviaaseriesofmechanismsthataredescribed underthetreatmentsystemsection.Theexternalevaluationofthe2005-2009nationaldrugsactionplan recommends to draw an inventory of current quality assurance mechanisms regarding drug treatment. Outcomesofthisinventorywillallowtofurtherharmoniseexistingroutines. DRUG TREATMENT STRATEGIES AND POLICY Inthemid-seventiesthecooperationbetweenStateandNGOsworkinginthesocialfieldhasprogressively gained structure. The first (financing) convention between the Ministry of Family and a series of NGOs, signedin1975,wasthestartingpointofwhatisknowntodayasthe“Conventionnedsector”.Overtheyears thecollaborationschemesbetweenStateandNGOsevolvedandwereextendedtothePublicHealthsector. In1998theso-calledASFTlaw56enteredinforce,regulatingtherelationshipbetweenStateandprivate organisationsworkinginthesocial,familyandtherapeuticfields. Treatmentneeds’assessmentaswellasqualitycontrollargelyrelyontheASFTlegalframeworkandthe existingnetworkofconventionnedserviceproviderswhohavetomeetaseriesofqualitystandardsandbe grantedaspecialaccreditationfromtheMinistryofHealth.Theelaborationofthedemandreductionsection ofthenationaldrugsstrategiesandactionplansbuildsupontheexpertiseandinvolvementofthereferred network.Adetaileddescriptionofcollaborationandcontrolmechanismsinplaceisprovidedbelow. 54 SOURCE:ClassificationofdrugtreatmentinEUmemberstatesandNorway,Expertmeeting,8-9February2002 55 ‘Drugfreetreatmentfocusonpsycho-socialandtherapeutictechniquesandisnotprimarilybasedontheroutineprescriptionofa substanceormedicamentwiththegoalofreducingorabstainingfromillegaldrugusetherebyimprovingthegeneralhealthofthe client’. 56 Loidu8septembre1998réglantlesrelationsentrel’Etatetlesorganismesœuvrantdanslesdomainessocial,familialetthérapeutique(entryinforce:24/09/1998) 89 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Thefirstspecialiseddrugcounsellingagency(JDH)wascreatedin1986andaddressedbothdrugaddiction and Youth. Originally, services developed bottom-up and were seeking financial support of the State. Preliminaryworkdoneintheframeworkofthefirstdrugactionplan1999-2004allowedtobetterassess national needs and to initiate and develop interagency coordination mechanisms. To date, treatment agenciesarespecialisedwhetherinpolydruguseincludingillegaldrugs,inalcoholabuse,orgambling,etc. Asfarasillegaldrugsareconcerned,drugcareprovidersaddressthewholerangeofsubstancesmeaning thatnospecialisedoffersexistaccordingtoagiventypeofsubstanceorproblemsrelatedtoit.Currently therearesignsthatthenationaldrugtreatmentstrategiesareevolvingtowardsamoreholisticconceptof addictiontreatment(includingillegalsubstancesrelatedaddictionsandothers). Asfarasnationalexpendituresfordrugtreatmentprovisionareconcernedpleaserefertochapter1. TREATMENT SYSTEMS Organisation and quality assurance Allspecialiseddrugtreatmentservicesarerelyingongovernmentalsupportandcontrol.Specialisedagencies need an accreditation to sign a convention with the Ministry of Health that guarantees their annual funding.Outpatientdrugtreatmentisprovidedfreeofchargebyspecialisedagencies.Inpatienttreatment anddetoxificationiscoveredbyhealthinsuranceschemes.Asfarassubstitutiontreatmentisconcerned, healthinsurancetakesinchargemedicalinterventionsandcounsellingandStatecoverspharmaceutical costsandpharmacyfees. NGOsinvolvedindrugtreatmentfallundertheobligationoftheabovereferredto‘ASFT’law(8/09/98)and thesubsequentgrandducaldecreeof10December199857,bothregulatingtherelation(dutiesandrights) betweenStateandNGOsororganisationsprovidingpsycho-medico-socialandtherapeuticcare.Theoverall managementofthereferredagenciesisensuredbya‘coordinationplatform’thatincludesamaximumof3 membersofthereferredinstitutionandatleastonerepresentativefromthecompetentministry.Allreferred institutionsworkinclosecollaborationandhavetobeviewedasaninterdependenttherapeuticchain. A seriesofformalcollaborationagreementshavebeensignedin2008and2009betweenvariousagenciesin ordertoinsurerationaluseofresourcesandthrough-care.The2015-2019 national drugs action plan foreseestofurtherdevelopthesesynergies. The governmental quality standard certification,asforeseenbythelaw‘ASFT’of8October1998, representsthemaininstrumentofastandardisedqualitycontrolofdrugtreatmentoffers.Generalguidelines onsettingrequirementsandhumanresources/clientskeysaresetbyagrand-ducaldecreeof10December 1998 regarding the accreditation of services from the medical, social and therapeutic field. Funding is, however,notadirectfunctionofmandatoryevaluationoroutputsrequirements.ThequalitystandardcertificationcommitsrespectiveNGOstoundertakenecessaryevaluationmeasuresoftheiractivitiesbymeans, however,they deem adequate. Drug treatment agencieshave developedproperevaluation strategies mostlyincollaborationwithexternalevaluators.Recentexamplesaretheevaluationofcurrentoffersinthe fieldofsocio-professionalintegration,whichfuturedevelopmenthasbeenpromotedbythenationaldrugs action plan, the implementation of a computer based evaluation procedure by the national substitution programmeandpreventioninterventionsinschoolsbyCePT.Theexternalevaluationofthedrugsaction planalsosignificantlycontributestoassessthefunctioningandthegapsofthenationaltreatmentnetwork. 57 Règlementgrand-ducaldu10décembre1998concernantl’agrémentàaccorderauxgestionnairesdeservicesdanslesdomaines médico-socialetthérapeutique(entryinforce18/12/1998) 90 Also,theRELIS databaseonproblemdrugusersprovidesrelevantdataforevaluationpurposessinceit includesdetaileddataondrugconsumepatterns,socio-economicsituation,riskbehaviourandtreatmentor lawenforcementcontacts,etc.Inthelongrun,drug‘careers’canbeanalysedbymeansoftheRELISindexingsystem,whichallowsfollowinguptreatmentdemandsandlawenforcementcontactsofindexeddrug users.Thesedatacanbeusedtoassesstheimpactandtheperformanceofspecifictreatmentapproaches.A practicalexampleoftheapplicationofevaluationresultsistobeseenintheconceptualisationandexternal evaluationofthenationaldrugactionplan2010-2014,whichdidgreatlyrelyonRELISdataandadhoc evaluationinitiativesfromfieldinstitutions. 2015 AnexternalassessmentofqualitymanagementmechanismsrunbyspecialisedNGOshasbeenforeseenby thenationaldrugactionplanandhasbecomeavailablein2011.Outcomeshaveshownthatcurrentquality assuranceroutinesimplementedwithininvolveddrugagenciesarehighlydiversifiedanddifferintermsof coverageandcomplexityrangingfrominternalactivityassessmentprocedurestoEFQMcertificationsforinstance.Theseoutcomesarehighlyvaluableforfutureimprovementofqualityassuranceanddocumentation routinesofdrugrelatedcareservices. Table 5.1 reports admission and contact statistics of national drug treatment agencies according to appliedtypologyfrom1994to2014.Intra-institutional multiple countsareexcludedmeaningthatall treatmentdemandersindexedbyagivenagencyareonlyindexedoncebythereferredagencyduringa reportingyear.Inter-institutional multiple countsarenotexcludedsinceagiventreatmentdemander mayhavecontactedseveralnationalagenciesduringagivenyear.Moredetailedadmissiondata,including low-thresholdagencies,areprovidedinrespectivesub-chapters. Availability and diversification of treatment Ascanbeseenonmap5.1drugtreatmentfacilitiesareregionalised,showing,however,ahighconcentration anddiversitywithintheareaofLuxembourgCity.Alllistedservicesarespecialisedwiththeexceptionof regionalgeneralhospitalsprovidingdetoxificationtreatmentviatheirrespectivepsychiatricdepartments.In July2005,thefirst‘consumptionroom’hasbeenopenedinLuxembourgCity.Ithasbeenintegratedinthe ABRIGADOcentreprovidingdaycare,nightshelterandlowthresholdservicestodrugaddicts. Itshouldbestressedthatnonationaldrugtreatmentserviceexclusivelytargetsagiventypeofsubstance useanditscorrelates.Currentlynationalservicesprovidecareforpersonspresentingvarioussubstanceuse relatedproblems. 91 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Map 5.1 Geographical coverage of specialised drug agencies in the Grand-Duchy of Luxembourg (status 2015) Germany Belgium Ettelbruck Rosport Mersch Schweich Manternach Luxembourg Esch/Alzette Legend : JDH:Counselling,substitution,low-thresholdandaftercare ABRGADO(CNDS):Lowthreshold ABRIGADO(CNDS):Nightshelter,Injectionroom IMPULS:Youthcounselling Quai57(Arcusasbl):Counsellingandreferral CHNP:Treatmentandreferral CTM:Residentialtherapy,reintegrationmeasures CTM:Aftercare,supervisedhousing(onlymainsite) Generalhospitalsprovidingdetoxificationtreatment 92 Germany StëmmvunderStrooss:Post-therapeuticcentre Thefollowingtreatmenttypologyisapplied: Themostrelevantnationaloutpatienttreatmentfacilityisthe‘JDHFoundation’.RegionalantennasofJDH arerespectivelyimplementedinLuxembourgCity,intheSouthandintheNorthoftheGrandDuchyandare entirelyfinancedbytheMinistryofHealth.Quai57(Arcusasbl)implementedinLuxembourg-Cityisprimarily acounsellingandreferralagency. A third specialised outpatient service is also implemented in Luxembourg-City (Alternative Counselling Centre).Themainobjectivesofthereferredcentrearethefollowing: 2015 Outpatient: services and offers for adults •Establishafirstcontactwiththedrug-addictedclients. •Help the drug-addicted clients in the development of a therapeutic project with orientation either towardstheintermediate-termstructures,ortowardsresidentialtherapycentres. •Organizationofdetoxificationsinlocalpsychiatricservicesorfurtherpsychotherapeuticinterventions. •Informativeandtherapeuticdiscussionswiththedrug-addictedclientsandtheirfamiliesbeforeand afterthedetoxification. Furtheragenciesprovidesocialcareortherapeuticsettingsthatareattendedbydrugaddicts.Theseagencies,however,rarelyprovidedrugspecifictreatmentandseparatedatabreakdownsarenotavailable. Outpatient: services and offers for minors Specialiseddrugcareagenciesforminorsexistinthecentreandsince2007inthenorthofthecountry. Althoughdrugcounsellingagenciesacceptunderagetreatmentdemanders,partofthelatterarereferredto aspecialisedserviceestablishedinthecentreofthecountry(Impuls). Outpatient: substitution treatment Substitution treatment is currently defined as a medical assisted treatment with opioids’ agonists and antagonists (and antagonistic agonists). The objectives of substitution and maintenance treatment are manifold.Theyrangefromno-digressivedose,out-patientlowthresholdmaintenancetoabstinenceoriented (digressivedoses)rehabilitationoffers.Theprimarygoalisthepsychosocialandmedicalstabilisationofthe patient by replacing ‘street’ drugs by quality controlled substitution drugs. The further development and outcomeofthetreatmentisassessedindividually.Bothcomponents,conditionofthepatientandreduction ofpublicnuisanceareconsidered. Substitution treatment is provided at the national level since 1989 (JDH). Until the beginning of 2001, however,therehasbeennolegal frameworkregulatingdrugsubstitutiontreatment.Thelawof27April 2001modifyingthebasicdruglawof19February1973introducedalegalframeworkforsubstitutionand maintenancetreatment.Thegrandducaldecreeof30January200258regulatesthepracticalmodalities ofsubstitution.Thereferredlawregulatesdrugsubstitutiontreatmentingeneralratherthanitlegalisesa singlenationalsubstitutionprogramme.Thelawdoesthisbymeansofsubstitution treatment licenses grantedtoMDsandspecialisedagencies,theapplicationoftrainingrequirementsforprescribingMDsand adequatecontrolmechanismsofmultiple prescriptions(i.e.centralisedregisterofsubstitutedpatients). Itshouldbestressedthatfollowingtheapplicationofthenewlegalframework,therestillexistsastructured and multidisciplinary substitution treatment programme (JDH-mainlyliquidoralmethadoneprovidedbyspecialisedagencies)anda substitution treatmentofferprovidedbyfreelancestate licensedMDs(MEPHENON®,METHADICT®andSUBUTEX®). 58 Thedecreeof30January2002regulatingthemodalitiesofsubstitutiontreatmentcanbedownloadedat:http:www.eldd.emcdda.org 93 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Until2001,methadoneandbuprenorphinehavebeenprescribedaspartofalong-termtreatmentwitha mediumorlong-termabstinencegoal.Thereare,however,aseriesofcasesinwhichsubstitutiontreatment has to be considered rather as a harm reduction or maintenance measure than an abstinence oriented therapeuticaction.Thegrand-ducaldecreeof30January2002listsmedicamentsaswellaspreparations containing methadone (liquid oral form in programme and pill form in lower threshold prescription) and buprenorphine if the notice mentions substitution treatment as a possible therapeutic indication. Furthermore, morphine-based (salts)medicationscanbeprescribedifthelistedsubstancesaredeemed inadequatebymedicalauthority.Finally,thedecreeallowsforheroinprescriptionintheframeworkofa pilotprojectmanagedbytheDirectorateofHealth.Thelist of substitution substancesmayberapidly modifiedbyamendingthereferreddecree.Inadditiontodrugprescriptionandmedicalcare,thegrandducal decreeondrugsubstitutiontreatment(30/01/2002)definesaseriesofpsychosocialcounsellingservices to be provided by licensed specialised centres. Licensed MDs may refer substitution patients to licensed treatmentcentresformorein-depthpsychosocialcounselling. DivertedMEPHENON®(methadoneinpillformprescribedbyaccreditedMDs)isfoundonthenationalblack market.Inthatrespect,acentral substitution registerhasbeenimplementedjointlybythe‘Surveillance CommissiononSubstitutionTreatment’ 59’,theNationalDrugCoordinatorandinvolvedspecialisedtreatmentproviders.Multipleprescriptionscouldbemarkedlyreducedsincethelaunchofthenationalsubstitutionregister.ThesubstitutiontreatmentsurveillancecommissionhasbeenreformedandsinceAugust2010 itischairedbytheNationalDrugCoordinator. Outpatient: low threshold services and offers CurrentlytwoagenciesofferharmreductionservicesintheCentre,theSouthandtheNorthofthecountry includingofferssuchasdayandnightshelterandsupervisedinjectionfacilities(currentlyonlyinthecentre).Anewintegratedlowthresholdcentrefordrugaddictsisplannedtobeimplementedinthemaincity oftheSouthofthecountry.ThefurtherdevelopmentofharmreductionservicesintheNorthispartofthe nationaldrugactionplan.Inthiscontext,anewlow-thresholdofferhasbeenimplementedintheNorthof thecountryin2014. Inpatient: detoxification services and offers Physicaldrugdetoxificationisprovidedby5regionalhospitalsviatheirrespectivepsychiatricunits.Themost importantdetoxificationunitimplementedwithinaspecialiseddepartmentoftheCHNP(15detoxification beds)hasbeenrestructuredanddoesnotprovidedetoxificationtreatmentanymore.The‘CentreHospitalier duKirchberg’hasjoinedthelistofnationalinstitutionsprovidingdetoxificationtreatmentin2005.Medical interventions and psychosocial support are provided to control and reduce withdrawal symptoms in the framework of a 1-2 week detoxification programme. Ideally, detoxificated patients are referred to more psychotherapeuticorientedinstitutions. 59 Thedecreeof30January2002replacestheformer‘MethadoneCommission’bythe‘Surveillancecommissiononsubstitutiontreatment’mandatedtocontrolallaspectsofsubstitutiontreatmentatthenationallevel.Establishedin2002,itiscomposedofdelegates fromtheprogramme,theDirectorateofHealth,twopharmacistsandtwoGPsaffiliatedtotheprogramme,andisinchargeofadmissions,releasesandexclusionsofsubstitutiontreatmentdemandersorpatients. 94 Inpatient: services and offers for adults Thenationalresidentialtherapeuticcentrecalled‘Syrdallschlass’(CTM-CHNP)issituatedintheEastofthe G.D.ofLuxembourg.ThetherapeuticprogrammeoftheCTMisdividedintothreeprogressivephases.The durationofatherapeuticstayvariesfrom3monthsto1year. 2015 Detoxificationtreatmentisprovidedbypsychiatricunitswithinfivegeneralhospitals: CentreHospitalierduNord–Ettelbrück(North) CentreHospitalierEmileMayrisch–HVEA(South) CentreHospitalierdeLuxembourg–CHL(Centre) Zithaklinik(Centre) HôpitalKirchberg(Centre) Inadditiontoindividualandgrouptherapies,thecentreofferstheopportunitytofollowtrainingactivities inseveralprofessionaldomainsandalsooffersposttherapeuticaccommodationfacilities.Thefinalobjective isthepsychological,professionalandsocialreintegrationoftreatedclients.Thelatterishighlyfacilitatedby thequalityofprovidedprofessionaltrainingtopatients.Thecollaborationwithseveralemployersdisposed toemployex-drugaddictsandtheactiveinvolvementofsocialservicesofferafairsocialandprofessional framingtoreleasedpatients. The national drug action plan 2000-2004 had foreseen the extension of CTM offers by creating a networkofmodular therapeutic annexesforspecifictargetgroupsasforinstancepregnantwomen,drug addictedcouples,treatmentdemandersonmethadone,etc.TheseannexesareoperationalsinceSeptember 2002andaresituatedinthevicinityofthemaincentre(seemap5.1)inordertotakeadvantageoftraining andsocialreintegrationfacilitiesofferedbytheCTM.Basedonpastexperience,the2005-2009drugsaction planhasforeseenthefurtherdevelopmentoftheseannexes.In2008anewannexprovidingtherapeutic offerstospecifictargetgroupssuchasmotherswithchild/childrenorpatientsinthelasttherapyphasehas becomeoperationalontheverysiteofthemaincentre. In2014,StëmmvunderStroossasblopenedanewpost-therapeuticcentreforpersonshavingbeentreaed foraddictivebehaviourinSchoenfels.Time-limitedhousinganddayoccupationisprovidedwithamedium termsocialanre-integrationobjective. Asthenationalinpatienttherapeuticfacilitiesarelimitedandnotcoveringthewholespectrumofdrugrelatedsymptoms(e.g.doublediagnosis)aseriesofpatientsarereferredtospecialisedinstitutionsabroad. Ifapproved,relatedcostsarecoveredbythenationalsocialsecurityschemes. Inpatient: services and offers for minors Aspecialisedresidentialcentreforproblematicyoungstershasbeenopenedinthebeginningof2007inthe NorthofthecountryunderthemanagementofCHNP.Anewprojectdefinedasaresidentialreferraland rehabilitationcentreforminorsinaruralsettingisinitsplanningphase.Thereferredcasemanagement programmewillcontributetofillcurrentgapsinthecaresystemforminors. 95 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 CHARACTERISTICS OF TREATED CLIENTS AND TRENDS OF CLIENTS IN TREATMENT Table5.1summarisesdrug-relatedinstitutionalcontactsofPDU.Inter-institutionalmultiplecountsarenot excludedmeaningthatagivenPDUcouldbeindexedtwiceandmore.Hence,thesedatadonotprovidethe nationalprevalenceofPDUbuttheyallowfollowinguptheincreaseorthedecreaseofthelatter. Thepresentsectionisdividedinageneraldescriptionofthedrugtreatmentpopulationandamorein-depth analysisofclients’characteristicsandobservedtrends.BothpartsarebasedonRELISdataandonin-house statisticsofspecialiseddrugtreatmentagenciesatthenationallevel. OverallthenumberofpersonsshowingdrugrelatedcontactswithnationalDRorSRagenciespeakedin 2010.Both,thenumberofdrugtreatmentdemandsandthecontactswithlawenforcementagencieshave beendiscontinuouslyincreasingsince2000/2001.Thenumberofsubstitutiontreatment(OST)demands beguntoplateauaround2002andshowedatangibleincreasein2009tostabiliseanewbetween2010 and2014.Thenumberofadultout-andinpatientclientsishighestsincereported.Since2009,themost remarkableincreasehasbeenobservedinoutpatientdrugfreetreatmentdemands.Thenumberofcontacts inlowthresholdfacilitieshasbeendecreasingsince2011(2010:140,093contacts;2012:127,080contacts; 2013:124,048;2014:131,375).Accordingto2013RELISdata,around6.6%(8%)ofrespondentsarefirst treatmentdemanders,alltreatmentcentresincluded.Asfarasfirst treatmentdemandersareconcerned, 16%arefemalesfor84%ofmales. Ofclientsindrugtreatment(alltreatmentsandalltypesofunit),70%(81%)aremalefor17%(19%) females.Themeanageoftreatmentdemandershassignificantlyincreasedduringthelasttenyears(1997: 28years/2013:33.7years)andthismainlybecauseofanobservedincreaseinaveragemaleage(1997: 28Y2M/2013:33Y8M).Themeanageofthefemaleclientsisslightlylower(2013:33Y3M).Respectively 50.5(45.2)%ofclientsintreatmentarenatives.Thepopulationofnon-nativesconsistsforthevastmajority ofPortuguesenationals,followedbyFrench,Italian,Belgian,Cap-VertandGermancitizens. Regarding the educational level of the clients in treatment in 2013, 62% have completed primary or complementary school, 19.2% have completed secondary school and 3.1% obtained a higher degree. 14.5%ofrespondentsreportedstableemployment(importantdecrease–1997:65%)against62.3%who are inactive or unemployed. Furthermore, 11.8% are students or engaged in a training contract. 42.2% (35.7%)ofindexedtreatmentdemandershadexperiencedoneormoreoverdoses.Asfarastheexchange ofsyringesisconcerned,21.8%(25%in2012and32.9%in2011)reportedthattheyneversharedsyringes duringtheirlifetime,42.9%(44.6%in2012and51.7%in2011)duringthelastmonth.IDUcombinedto polydruguseisthemostobservedconsumepatternindrugtreatmentdemanders. 96 2012 2013 2014 2000 2,112 182 476 916 1,065 2004 183 484 928 1,044 2006 124 397 1,162 1,050 2008 119 324 1,020 1,128 2009 128 297 980 1,163 2010 153 250 1,175 1,160 2011 224 1,963 232 2,530 193 2,210 Source: RELIS2015/CNS 2,318 1,900 1,816 1,819 89 267 1,307 1,126 2013 64 310 1,296 1,121 2014 306 1,782 226 2,066 223 2,791 2015 4,951 5,084 5,806 2,187 2,762 2,403 2,088 2,295 3,015 4,031 4,768 4,539 4,455 4,542 4,778 5,330 5,141 332 1,487 TOTAL NUMBER OF PERSONS SHOWING DRUG-RELATED INSTITUTIONAL CONTACTS (Multiplecountsnotexcluded) 243 1,573 1,919 92 1,808 SUB TOTAL B: Number of drug law offenders (Multiplecountsnotexcluded) 101 2,217 161 1,758 Nationalprisons Police-JudicialPolice-Customs 127 262 1,294 1,180 2012 NUMBER OF DRUG TREATMENT DEMANDERS (intra-institutional multiple counts excluded) 2,450 2,639 2,639 2,733 2,591 2,568 2,738 2,863 2,789 2,791 153 429 828 1,040 SUPPLY REDUCTION: LAW ENFORCEMENT INSTITUTIONS LOW THRESHOLD 13,083 29,536 39,526 55,808 78,415 110,674 140,093 123,465 127,080 124,048 131,375 AGENCIES (contacts) SUB TOTAL A: Number of drug treatment demanders (Multiplecountsnotexcluded) 2002 DEMAND REDUCTION: SPECIALISED DRUG TREATMENT 2011 158 316 2010 INPATIENT -Specialised -Hospitalcare 2009 636 1,002 2000 2002 2004 2006 2008 NUMBER OF ADMISSIONS NUMBER OF CONTACTS (Low threshold) OUTPATIENT -DrugFree -Substitution SETTING Table 5.1 Drug-related institutional contacts (Inter-institutional multiple counting included) 97 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Belowispresentedamoredetailedanalysisoftreatmentdemandsandtrendsaccordingtotypeoftreatment: Outpatient: services and offers for adults RELEVANT TREND:Increase of male treatment demanders (76% male, 24% female). Increase of the proportion of clients aged 30 and more (2014 88%: 2013: 86% / 2012: 61.9% / 2008: 61%). A current trend is also to be seen in the increasing number of young mothers or couples with their child/children seeking out- and inpatient treatment. Afterseveralyearsofstability,nationaloutpatientdrugcounsellingcentreshavebeenshowingdecreasing admissionratesfrom2011onwardsanddecreasingfirsttreatmentratesintra-andinter-agencywide.Gender distributionshowedanoverallincreaseofmaleclientsoverthelast10years.Agedistributionsarevarying accordingtothegeographicalsituationoftreatmentcentres.Allinall,however,theproportionoftreatment demandersaged30yearsandmorehasmarkedlyincreasedduringrecentyears(201488%:2013:86%/ 2012:61.9%/2006:57%).Treatmentdemandsfromunderageclientstendtodecreaseuntil2007and stabilisedsincethen,mainlybecausespecialisedagenciesforminorshavebeenimplementedmeanwhile. Treatment demands for problem i.v. opiate use associated to multiple-use is the main demand pattern. Cannabis-relateddemandshaveshownaclearupwardtrendsince2009(25%).Theprevalenceofcocaine use-relatedtreatmentdemandsisstable,however,bearinginmindthattheexactprevalenceisdifficultto assessasinmostPDUconcomitantuseofheroineisobserved. Outpatient: services and offers for minors RELEVANT TREND: Increase of the number of episodes. Cannabis-related problems are the main consultation motives.Adecreasingmajority(83%)ofclientsaremale.Cannabisuseisthemain reasonoftreatmentdemandswitnessingacurrentlyincreasingtrend.However,theuse/abuseoflicitdrugs andpolydruguseisincreasinglyreportedasreasonoftreatment.Anincreasingproportionofyoungsters presentingpsychiatricsymptomsand/orsociallydeviantbehaviourinadditiontodrugabusearereported byspecialisedfieldagencies. Outpatient: substitution treatment RELEVANT TRENDS: Overall stabilisation of OST patients since 2009. Between 2005 and 2012 decrease of number of patients in structured JDH substitution programme and slow increase in substitution treatment prescribed by licensed MDs – Stabilisation of gender ratio (3 males/ 1 female) – Increase of substitution treatment demanders being aged between 45 and 49 years. Thenumberofpatientsadmittedtothenationalmultidisciplinarysubstitutionprogramme(JDH)hasbeen sensiblydecreasingfrom2005to2012andincreasedagainin2014,(113patientsin2014).36%(47%)of clientswerefirstsubstitutiontreatmentdemandersin2014.Theproportionoffemalesubstitutiontreatment demanders(23%)ishigherthantheproportionoffemalePDUintheoveralldrugtreatmentpopulation. 17.7%(25%)oftheclientsinsubstitutiontreatmentareagedunder30,36.3%(41.7%)arebetween30 and39,while46%(33.5%)areover40yearsold.Themean ageofclientshassignificantlyincreasedover thelast10years(currently+/-38years),whichisconsistentwiththeoverallagingtrendofPDU.Polydrug useisthemostobservedconsumepatterninsubstitutiontreatmentdemanders. 98 2015 Thetotalnumberofpatientswhodidreceivesubstitutiontreatmenthasknownasteepincreasebetween 2008and2009 [(1,158patientsin2010multiplecountsexcluded(2008:961)].Since2009astabilisation inthenumberofOSTdemandershasbeenrecorded(2014:1,121). TheNationalHealthFound(CNS)annuallyprovidesthenumberofpatientsreceivingreferredsubstitution drugsonprescriptionaswellasthenumberofprescribingMDs.Oneobservesasoundincreaseofsubstitution demandsaddressedtoaccreditedliberalMDsuntil2010andanoveralldecreaseofthenumberofpatients choosingthemultidisciplinaryJDHprogramme,moredemandingintermsoftreatmentconstraints.Over 95%ofprescriptionsdeliveredintheframeworkofsubstitutiontreatmentrefertomethadonefollowedby buprenorphine. Table 5.2: Outpatient prescription of substitution drugs by the national network of licensed MDs /(1999-2014) YEAR Number of indexed patients (doublecountingcontrolled) 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 844 849 820 913 945 970 939 979 1,050 1,128 1,163 1,160 1,180 1,126 1,121 Number of licensed MDs (doublecountingcontrolled) 124 129 138 Source :CNS2015 Table 5.3: Age distribution (%) of patients substituted by the national network of licensed MDs (2008-2014) AGE CATEGORIES 15-19 years 2008 2009 2010 2011 2013 2014 2 1 0.5 0.1 0.3 0.5 20-24 years 9 9 7 7 3 3.5 25-29 years 17 16 15 13 11 10.4 30-34 years 19 20 20 19.3 18 17 35-39 years 19 18 20 20.4 20 20.3 40-44 years 18 18 17 17 19 18.9 45-49 years 9 11 12 14.7 16 17.3 50-54 years 5 5 6 6.4 8 8.6 55-59 years 1 1 1.5 2 4 3.3 60-64 years 1 1 1 0.1 0.7 0.2 Source :CNS2015–datareformattedbyNFP Theproportionofpatientsagedlessthan30yearshasbeendecreasingandtheproportionofpatientsaged 45andmoreincreasingbetween2008and2014. 99 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Outpatient: low threshold services and offers RELEVANT TRENDS: Thenumber of contactsindexedbylowthresholdagencies(2014:131,375)has increasedmarkedlybetween2006and2010(2010:140,093/2005:47,739),andstabilisedsince2011. 200,000to250,000sterilesyringesaredistributedandrecollectedyearlybythesameagencies(increasing trendin2014).Theproportionofnew clientswithinlowthresholdsettingsisonthedecrease.40%of clientsareaged25to34yearsfollowedby35%ofclientsaged35to44years.Approximately80%of treatmentdemandersaremale. Inpatient: hospital based care RELEVANT TRENDS: Drugdetoxificationunitsthroughoutthecountryhavebeenshowingacontinuous increase regarding number of patients until 2006 (484) and then onwards a steady decrease to 277 patientsin2014(423episodes).Genderdistributionhasremainedfairlyunchangedbetween2002and 2014.Multipledruguse,includingheroin,isthemainreasonfordetoxificationdemands. Inpatient: services and offers for adults RELEVANT TRENDS: The number of inpatient treatment demanders (detoxification treatments excluded) has been showing a fairly stable trend over the last 10 years. The proportion of first treatment demands sets around 49% (47%). Heroinaspreferentialsubstanceisreportedby60%oftreatmentdemanders.57%ofpatientsareolder than30years.74%ofpatientsarenatives. In2009,aweakdecreaseinpreferenceforintravenousheroinuse(1997:60%,2009:49%)wasobserved comparedto2008(52%).Thistrendhasbeenconfirmedin2010(38%),2012(24%),2013(33.3%),and 2014.Theheroininhalationmode(2013:41.6%,2012:35%,2011:20%,2009:20%)hasbecomemore prevalentcomparedto2008(14%).Polydruguseisthemostobservedconsumepattern(63.3%).Thei.v. heroinsub-populationshowsthehighestmeanage(35.5%)ofalltreatmentgroups.Cocaineuseasmain reasonoftreatmentdemandshowedasignificantincreaseinrecentyears. Treatmentdemandsrelatedtoecstasyusearerare(1-3%)andhaveshownafairstabilityoverthelastyears. ThesamecommentsapplytoATSuse. 100 INTRODUCTION Atthenationalleveltwodrug-relateddeathsindexingroutinesdocurrentlyexist: TheSpecialDrugUnitoftheJudicialPolice(SPJ)maintainsaregisteronacutedrugdeaths(RSPJ).TheRSPJ indexesalldirectoverdosecasesduetoillicitdrugusedocumentedbyforensicevidence.Aspoliceforces areroutinelyinformedbymedicalemergencyservicesincaseofasuspectedoverdosecase,theyareableto collectevidenceatthesiteoftheincidentandconfirmornot,incombinationwithpostmortemtoxicological evidence,thesuspectedoverdose.RSPJappliesthefollowingdefinitionofacute/directdrug-relateddeath: 2015 6. HEALTH CORRELATES AND CONSEQUENCES ‘Lethal intoxication, voluntary, accidental or of undetermined intent, confirmed by forensic and contextual evidence, and caused directly by the use of illicit drugs or by any other drug(s) if the victim has been known to be a regular consumer of illicit drugs.Death has occurred due to an adverse somatic reaction to substance intake’. The statistical department of the Directorate of Health maintains the General Mortality Register (GMR) indexingalldeathsthatoccurredonthenationalterritorybymeansofdeathcertificatesprovidedbyMDs. Since1998theGMRappliesthe10threvisionoftheInternationalClassificationofDiseases(ICD-10).Special softwarejointlydevelopedbythestatisticaldepartmentandthenationalfocalpointallowsextractingdrugrelateddeathcasesfromtheGMRbytheapplicationofapredefinedstandard(e.g.DRD). Bothsourcesareindependent,meaningthatfortheSPJregisterdatacollectionoccursviapolicerecords andforensicevidence,whiletheGMRisupdatedaccordingtoinformationcontainedindeathcertificates. Discrepanciesbetweenthereferredregistersmainlyoriginatefromdifferentencodingroutines(e.g.death certificatesoftenonlymentionprimarycauseofdeath)explainingthefactthattheDRDv0.3systematically underestimatestheSPJbasednumberofdrug-relateddeathsascanbeseeninfigure6.6. EventhoughDRDbaseddataisprovidedtotheEMCDDA,nationalfiguresondruginduceddeathspublished inthenationalannualdrugsreportare,forreasonsexplainedabove,basedontheRSPJwhosecasedefinition iscompatiblewiththeEMCDDAdefinition:[…] deaths that are caused directly by the consumption of drugs of abuse. These deaths occur generally shortly after the consumption of the substance(s).(EMCDDA) Infectious diseases, including HIV and viral hepatitis have to be reported (notification procedure) when diagnosedtotheDirectorateofHealth(MinistryofHealth)thatcompilesdataandisinchargeofnationwide epidemiological follow up. These data do however not allow to breakdown infection prevalence accordingtoPDUstatus.ThenationaldrugmonitoringsystemRELISthereforeallowstogatherself-reported dataoninfectiousdiseasesinPDU.Furthermorespecificdiagnosedbasedstudiesprovidecomplementary information.ThereportincludesdatafromthelateststudyoninfectiousdiseasesinPDU(Origer&Removille, 2007)basedonserologicaltestresultstoassesscurrentprevalenceratesandapplyvaccinationschemes whenmedicallyindicated. 101 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition DRUG-RELATED INFECTIOUS DISEASES HIV/Aids, viral hepatitis, STD, tuberculosis, other infectious morbidity InjectingdrugusecontinuestodrivetheexpansionoftheHIVepidemicinmanycountriesaroundtheworld. In2014,UNODCestimatesthatthereare12.7millionpeoplewhoinjectdrugsworldwide,andofthese,1.7 millionarelivingwithHIV,representingaglobalHIVprevalenceof13.1%amongpeoplewhoinjectdrugs. Dataondrug-relatedinfectiousdiseasesarecentralisedatnationallevel.Noregionaldatasetsexist.Official datafromthenationalRetrovirologyLaboratoryoftheLuxembourgInstituteofHealth(LIH)providethe number and proportion of IDUs in HIV infected patients. Between 1984 and 2014, 1,250 HIV infected personshavebeenrecordedatthenationallevel;160oftheformerwerereportedIDUs,whichleadstoan averageproportionofIDUsinthenationalPLWHIVpopulationof12.8%sincethereportingofthefirstHIV caseinLuxembourgin1984. Currently intravenous drug use appears to be the third most reported transmission mode of new HIV infectionssince1989(homo/bisexualandheterosexualtransmissionarecurrentlyinfirstandsecondposition respectively).Theproportionofintravenousdrugusetransmissionhasnoticeablydecreasedbetween1998 (23%)and2011(2.77%).ThelowestproportionofIDUtransmissionmodeeverrecordedwasobservedin 2011followed,however,byasubsequentincreaseconfirmedby2014data. Fig. 6.1 Proportion (%) of IVDU in newly diagnosed HIV patients (1985 - 2014) 45 30 15 0 1987 1989 1991 1993 1995 1997 1999 2001 2005 2006 2008 2009 2010 2011 2012 2013 2014 (7) (2) (4) (5) (3) (3) (6) (7) (7) (4) (5) (2) (4) (2) (8) (7) (18) Total 21.2 8.3 12.5 15.6 10.1 11.5 20.6 17.5 11.1 7.7 7.35 3.13 6.45 2.77 9.88 8.54 18.8 Source:LaboratoiredeRetrovirologie–LIH.2015(dataformattedbyNFP) The Origer and Removille study (2007)60 assessed the national HIV, HCV, HAV and HBV in the populationofproblematicusersofillicitlyacquireddrugsprevalenceviaserologicaltestresults.Furthermore, theauthorsperformedacrosssectionalanalysisoftherelationbetweenthestudiedinfectionsandselected observable factors, to increase the national vaccination coverage and to refer infected persons towards appropriatemedicaltreatmentcentres. 60 Downloadableat:http://www.relis.lu 102 Table 6.1: Prevalence of hepatitis B surface antigens (HBsAg), antibodies to hepatitis B core antigen (anti-HBc), hepatitis C virus (anti-HCV), and HIV (anti-HIV 1 and 2) in PDU and ever-injectors according to national recruitment settings Total number Anti-HBc and/or HBsAg* of respondents † N‡, n (%; 95% CI) N n Anti-HCV (%; 95% CI) N Anti-HIV 1 and 2 n (%; 95% CI) Total sample 362 310 67 (21.6;17.1to26.2) 343 245 (71.4:66.6to76.2) 272 8 (2.9;0.9to4.9) Everinjectors§ 310 239 59 (24.7;19.6to29.8) 268 218 (81.3;71.4to91.2) 202 5 (2.5;0.2to4.8) Outpatientdrug treatmentcentres 159 147 24 (16.3:10.3to22.3) 158 92 (58.2:50.5to65.9) 158 3 (1.9;0.0to4.0) Inpatientdrug treatmentcentres 61 53 (75.4;64.6to86.2) 49 0 (0.0;0.0to0.0) Prisons 135 110 35 (31.8;23.1to40.5) 124 107 (86.3;80.2to92.3) 65 5 (7.7;1,2to14.2) 8 (15.1;5.5to24.7) 61 46 2015 Mainresultsarethefollowing: *TworespondentswithvalidbloodtestserologywereHBsAgpositiveonly †Numberofrespondentsforwhomvalidbloodtestserologyforatleastoneinfection(HBV,HCVorHIV)wasavailable ‡NumberofrespondentsforwhomvalidbloodtestserologyforHBVwasavailable §Respondentsthathaveinjectedatleastonceintheirlifetimeadrugfornon-therapeuticreasons Source:OrigerA.&SchmitJC,2012 Since1996,thenationaldrugmonitoringsystemRELISallowsforbreakdownsofHIVandAIDSdatabyIDU andtreatmentstatus.In2014(N=199),83%ofRELISindexedPDUreportedaHIVtestduringthelast12 months.ThetestingratesoffemalePDUwereslightlylowerthanthoseofmalePDU. Fig 6.2 Synopsis of national data on HIV infection rates in drug using populations (valid %) 9 8 HIV/PDU self-reports HIV/PDU serology HIV /DTR self reports HIV/ IDU self-reports HIV/IDU DTR self-reports HIV/IDU serology HIV/IDU prison 7 6 5 4 3 2 1 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source:RELIS2015/OrigerA.&SchmitJC,2012 103 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Table 6.2 : Synopsis of national data on HIV infection rate in drug using populations (valid %) YEAR HIVrateinproblemdrugusers (RELISself-report) 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2.9 4.3 4.07 4.49 3.88 3.98 HIVrateinproblemdrugusers (serology-based) (Origer&Removille,2007) 3.31 2.9 2.90 / 3.39 3.82 5.08 6.09 3.94 3.54 / / / / / / 3.5 5.07 / / HIVrateindrugtreatment demanders(DTR) (RELISself-report) 3.4 4.87 4.78 4.32 3.88 4.93 3.84 3.49 4.13 2.96 4.83 7.22 3.85 HIVrateincurrentIDU (RELISself-rep.) 3.3 3.6 3.41 4.17 5.10 3.96 3.48 1.75 8.14 4.26 4.84 1.9 5.94 HIVrateincurrentIDU treatmentdemanders (RELISself-report) 3.9 3.9 4.24 4.32 4.24 6.41 4.59 3.33 4.27 3.77 4.14 3.7 5.31 4.08 HIVrateinlife-timeIDU (serology-based) (Origer&Removille,2007) HIVrateincurrentIDUprisoners / (Schlink,1998) / / / / / 2.76 4.32 0.76 4.24 7.29 3.76 3.92 5.66 2.50 / / / / / / / / / / / / / / / / / / / Source: RELIS2015 Table 6.3 : Synopsis of national data on AIDS rates in drug using populations (valid %) YEAR 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 AIDSrateinproblemdrugusers (RELIS) 1.25 1.35 2.03 1.72 AIDSrateindrugtreatment demanders 1.66 1.71 2.13 1.81 1.19 1.86 0.87 1.33 3.05 1.95 0.79 1.67 1.76 2.43 1.60 2.04 2.69 2.37 1.65 2.64 0.92 1.96 3.96 2.05 0.65 2.6 1.41 1.28 Source: RELIS2015 HIVratesincurrentPDUhavebeenvaryingoverthelasttenyearsalthoughinquitenarrowmarginsfiguring 3to5%.In2010,however,basedonself-reporteddatafromRELIS,theHIVrateincreasedforallcategories figuring6to8%.In2011,2012,2013.However,HIVratesincreasedin2014(5to6%). From2005to2010,theHCVinfectionratedecreasedforallPDUandfordrugtreatmentdemanders,butthe samerateshowsvariationsforIDUs.In2013,HCVinfectionrateshaveincreasedforallcategories,especially forallPDUanddrugtreatmentdemanders,andremainedstablein2014.AIDSrates,afteradecreaseover 3years,increasedin2013forbothcategories,PDUanddrugtreatmentdemanders,anddecreasedagain in2014. 104 Table 6.4 : Synopsis of national data on HCV infection rate in drug using populations (valid %) 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Self-reportedHCVrateindrug users(RELIS) 32 46 50 49 HCVrateinPDU (Origer&Removille) / / / / Self-reportedHCVrateindrug treatmentdemanders 41 53 54 54 HCVrateinIDUprisoners (salivatests) / / / / Self-reportedHCVrateinIDU (RELIS) 50 53 56 53 HCVrateinever-injectors (Origer&Removille) / / / / 59.92 64.55 64.94 64.95 64.06 63.39 50.55 49.61 61.45 54.19 61.71 61.49 / / 71.40 / / / / / / / / / 60.49 66.16 66.22 63.23 63.08 61.11 53.79 50.47 62.31 60.27 67.24 66.39 / / / / / / / / / / / / 2015 YEAR 67.97 74.14 74.38 69.58 72.02 65.48 58.94 62.63 74.81 74.21 77.78 76.61 / / 81 / / / / / / / / / Source: RELIS2015(Origer&Removille2007) Summarily,HCVprevalenceinPDUshowfairvariations.Afteramarkeddecreasein2009and2010,and laterin2012,itreached61.7%in2013,andremainedstablein2014,at61.5%. OTHER DRUG-RELATED HEALTH CORRELATES AND CONSEQUENCES Psychiatric co-morbidity (Dual diagnosis) Todateanygenuinestudyonco-morbiditypatternsinPDUhasbeenperformedatthenationallevel.Data presentedinthepresentchapterhavebeenprovidedbyspecialiseddrugagenciesandtheRELISdrugmonitoringsystemandthusreflectexperiencesandtrendsasobservedduringrecentyears. Mostcommonmentaldisordersobservedinclientsseekinghelpinspecialiseddrugagenciesorincontact with other institutions are: anxiety, depression, neurosis, psychosis and borderline behaviour. Residential drugcaresettingsestimatethat10%oftheirclientsshowpsychoticsymptoms.Furthermore,Post-Traumatic StressDisorders(PTSD)aremostcommonandshowgreatsimilaritieswithborderlinebehaviouralaspectsas forinstancerapidlychangingmoodandauto-destructivetendencies. AccordingtoannualdataprovidedbythenationaldrugmonitoringsystemRELISthefollowingpicturecan bedrawn: Fig. 6.3 Previous contacts with psychiatric services of RELIS indexed drug users. 1998- 2014 100 90 81 83 87 87 84 82 88 87 85 80 79 83 83 86 79 80 72 70 75 Contacts with psychiatric services 60 50 40 30 20 10 0 1998 (214) 1999 (211) Source: RELIS2015 2000 (247) 2001 (313) 2002 (380) 2003 (320) 2004 (301) 2005 (298) 2006 (310) 2007 (292) 2008 (256) 2009 (235) 2010 (168) 2011 (238) 2012 (336) 2013 (282) 2014 (255) 105 è Fig 6.4 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Reasons for psychiatric care demands 1998-2014 80 60 40 20 0 1998 (209) 2000 (263) 2004 (297) 2005 (312) 2008 (248) 2009 (147) 2010 (127) 2011 (175) 2012 (229) 2013 (219) 2014 (182) Counselling 8 11 13 15 9 37 40 45 53 47 49 Confinement 4 5 6 5 5 28 28 25 29 26 29 Detoxification 74 72 60 58 65 75 73 79 66 72 76 Emmergency 6 7 14 16 16 39 29 29 31 27 38 Other 8 6 7 5 5 5 9 7 13 7 11 Source: RELIS2015 Atthenationallevel,mostofdetoxificationtreatmentsareprovidedbypsychiatricdepartmentsofgeneral hospitals. Datafrom1996to2011revealafluctuatingbutfairlystablelongtermproportionofPDUshowingapsychiatrichistory,reaching,however,anhistoricalminimumin2012tostabiliseagainaround75%in2013. Nosignificantdifferencesofpsychiatricprofilesinclientsaccordingtothetypeofinstitutionalsettings. DDpatientsareconsideredasdrugtreatmentdemanderswithspecificandhighlydiversifiedneedsthat aredifficulttoencounterintraditionaldrugcareagencies.Theconceptof‘multiplevulnerabilities’,thatis, concomitantvulnerabilitiestodrugabuseandmentaldisorders,tendstoberecognisedbyprofessionals.DD patientsveryoftenpresentalackofbehaviouralstructureorstability.Usuallythosepatientsareunableto functioninaregulatedenvironment.Moreover,therequirementofmosttherapeuticsettingsincludethat thepatientssubmittodetoxificationtreatmentpriortoadmission.Thislatterrequirementisoftenimpossible tomeetwithDDclientsasdrugintakeoftenrepresentakindofself-managedauto-medication,dangerous tochangeradicallyatthebeginningofatherapeuticprocess.ItisthereforemostdifficulttointegrateDD patientsintraditionaldrugcaresettingsalsointermsofconsistencyofrulestoberespectedbyalldrug treatmentdemanders.Todate,nocarefacilitiesspecialisedindrugaddictionco-morbidityexistatthenationallevel.TheDepartmentofMedicalControlofSocialSecurityAdministration,incollaborationwithdrug agencies,assesseswhetheragivenpatientshouldbereferredtospecialisedinstitutionsinforeigncountries. Agreementsbetweenthelatteradministrationandaseriesofspecialisedcareagenciesabroadhavebeen made.Ifthereferraldemandisapproved,relatedcostsarereimbursedbySocialSecurity. AsfarastreatmentofDDpatientsinprisonisconcerned,acollaborationconventionbetweenthenational prisonadministration(CPL)andthenationalneuro-psychiatrichospital(CHNP)hasbeensignedin2002. The convention sets the framework for the creation of a psycho-medical department within prison and regulatesprevention,careandreferralofmentallydisabledaswellasalcoholanddrugdependentinmates. Therapeutic care, substitution treatment and counselling is provided ad hoc. In case of severe mental disorders,imprisonedpatientsarereferredtoahighsecuritydepartmentwithintheCHNP. 106 Somatic co-morbidity Health indicators retained by RELIS suggest a stabilisation of the general health state of indexed PDU exceptforHCVprevalence.In2014,79(81%)ofproblemdrugusersreportedaself-perceivedsatisfying generalhealthconditionagainst53%in1997.58%(53%)reportnonon-fataloverdose(s)duringlifetime whichrepresentsadecreasecomparedwiththepreviousyear. 2015 Compulsorytreatmentorconfinementdoesonlyoccurifthereisaprovedoffenceagainstthelawbywhich theoffenderisdeclaredirresponsibleofhis/herownbehaviour.Thisonlyoccursfollowingalegalpsychiatric expertise. Pregnancies and children born to drug users Seesub-chapterat-riskfamiliesinchapter3. DRUG-RELATED DEATHS AND MORTALITY OF DRUG USERS Direct drug-related overdose deaths MethodologicalinformationandDrug-relatedDeaths(DRD)datacollectionandprocessingroutinescanbe foundintheintroductionofthepresentchapterandinannexIunder‘Databasesandinformationsystems’. DRDv.3.0standard(selectionB)appearstobefairlyweakproxyofdirect,indirectandtotaldrugdeathsas indexednationallybytheRSPJ.Overalldrug-relatedmortalityshouldnotbeassessedbythesamestandard asfarasLuxembourgisconcerned. Thenumberoffatal acute overdosesindexedatthenationallevelhasshownanoveralldiscontinuous decreasesincethebeginningofthe21stcentury.In2000,26acutedrugdeathswereregisteredwhereas8 caseswerereportedin2014. Fig 6.5: Evolution of drug-related death cases and mortality rates per 100,000 inhabitants aged 15 to 64 from 2000 to 2014 30 25 20 15 10 5 0 2000 2002 2004 2006 2008 2009 2010 2011 2012 2013 2014 Acute/direct drug deaths: RSPJ (Special register) 26 11 13 19 10 14 12 6 8 11 8 Acute/direct drug-related mortality rate: RSPJ (SR) 8,93 3,66 4,2 6,16 3,04 4,15 3,5 1,7 2,21 2,97 2,04 Source: Origer2015 107 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Confronted to most recent national prevalence figures on problem drug users referring to data of 2009 (N = 2,070), (Origer, 2012), overdose rate in PDU situates at0.29%cases/PDU(1.1%in2000). The overdose rate in the national general population figured 6.43 overdose deaths per 100,000 inhabitants61in2000.In2013and2014,overdoseratesof2.97and2.04per100,000inhabitantsand 100,000inhabitantsaged15to64yearsrespectivelyhavebeenobserved. The overall discontinuous decrease of acute overdose cases from 1994 onwards has been associated to the regionalisation and extension of the methadone substitution programme as well as to the further developmentoflowthresholdfacilities.Thedecreasingtrendfrom2000to2002isthoughttobeamedium termconsequenceofthehigherproportionofnon-i.v.opiateusersobservedduringthatsameperiodfollowed byastabilisationaround4.5percent.Thepositiveevolutionofthenumberofdirectdrug-relateddeathsisto beassociatedtotheimplementationofthefirstnationaldrugconsumptionroomin2005.Consideringthat sincetheopeningin2005ofthedrugsinjectionroomaround1,800overdosevictimscouldbeassistedand reanimatedinthissamefacility,thelife-savingeffectivenessofsuchanofferisgiven. A retrospective study (1992-2006) on drug-related death cases performed in 2007 allowed a better understandingofriskandprotectivefactors(Origer,2008). Forensic data by the department of National Toxicology Laboratory on Health62 show that the most frequentlyinvolvedsubstanceinoverdosecasesisheroin,followedbymethadoneandcocaine.Tostressthat since2000,methadonepresenceinbloodsamplesofoverdosevictimshasbeenincreasing. 64%ofthevictimsaremaleandtheirmeanageatthemomentofdeathshowsanincreaseoverthepast 20years(in1992:28.4yearsandin2014:37.9years).Althoughthemeanageofdrugoverdosevictims hasbeenincreasing,thenumberofvictimsagedlessthan20yearsremainsrelativelyunchangedduringthe referredobservationperiod(1casein2014). Amajorityofacutedrugdeathvictimsareknownbylawenforcementagencies(+/-80%)fortheirdruguser ‘career’.Asfarastheplaceofdeathisconcerned,since2004approximately50-65%occurredatthevictims’ home,followedbypublicplacessuchascars,trainsorpublicbathrooms. Fig. 6.6: Gender distribution of direct drug-related death cases (1992 - 2014) (%) 100 80 60 40 20 0 2014 2013 2012 2011 2010 2009 2008 2006 2004 2002 2000 1998 1996 1994 1992 Females 13 36 13 50 0 29 30 5 23 18 26 6 24 17 18 Males 87 64 87 50 100 71 70 95 77 82 74 94 76 83 82 Source: RELIS2015 61 Allagegroups 62 DépartementdeToxicologieduLaboratoireNationaldeSanté 108 Table 6.5: Age distribution of direct drug death cases indexed from 1992 to 2014 2014 2013 2012 2011 2010 2009 2008 2006 2004 2002 2000 1998 1996 1994 1992 Total 1 3 2 1 1 1 2 2 2 2 3 2 2 2 2 1 1 2 1 2 2 3 2 2 2 1 1 4 4 2 5 2 2 2 1 3 2 1 4 3 2 2 1 1 8 6 6 4 1 1 4 1 3 1 2 2 5 2 4 3 1 Mean Age 37.7 36.9 37.7 Male Female 1 4 2 2 40.35 39 19.74 33.2 38.3 34 31.5 31 33.6 29.3 31 1 5 5 4 1 3 6 13 6 1 6 6 3 1 1 1 30.3 33.16 32.5 32.17 31.18 29 20 66 93 69 44 33 2015 < 20 20-24 25-29 30-34 35-39 40-44 45-49 ≥ 50 14 5 32.3 28.5 26.8 28.4 344 32Y5M 32Y8M 25 33Y8M Source: RELIS2015 In2012,themeanageofmaleoverdosevictimsshowedanimportantincreasecomparedtopreviousyears. Thisobservationhasbeenconfirmedin2013and2014(meanageofmalevictimsbeing39and40years, in2013and2014respectively).Theyoungestvictimwasaged19,7years(28yearsin2012)andtheoldest was61.4years(49yearsin2012).Nounderagevictimwasreportedin2014.Consideringthenationalityof overdosevictims,themajority(75%)werenatives.Recently,adecreasingnumberofvictimsofPortuguese originwasobserved. Fig. 6.7: Mean age of acute drug overdose victims (2001-2014) 40 35 30 25 20 Mean age OD cases 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 31.5 31.5 37.7 36.9 37.7 31.2 36.64 32.17 31.48 32.5 32.4 32.9 30.3 31 Source: RELIS2015 109 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Mortality and causes of deaths among drug users Theabovementionedstudy(Origer&Dellucci,2002)63,hasrevealedthat,asfarastheGrand-Duchyof Luxembourgisconcerned,themereapplicationoftheDRDstandarddoesnotallowforavalidcomputation ofdrugrelateddeathcases.Therefore,theauthorsdidcomputethetotalnumberofdrug-relateddeaths byaddingcasesoftheSRthatwerenotindexedbytheapplicationoftheDRDstandardtotheGMR.The figuresresultingfromcorrectedDRDv.3.0.dataarereferredtoas‘national selection’andprovidethe annualtotalnumberofcontrolleddrug-relatedfatalitiesatthenationallevel(11direct/acutedeathcases in2014). In2000,afirstcohortstudyonthemortalityinthenationaldrugpopulationhasbeenperformedbythe NFP in the framework of a multi-methods prevalence study (Origer & Pauly, 2000). The cohort included 242opiatedrugaddictsfollowedfrom1991to1999.Mortalitydatahavebeencollectedfromtreatment agencies, the RELIS database, the GMR and the Special Overdose Register of the SPJ. In accordance to appliedmethodologies,resultsshowmortality rates varying between 2.36 and 2.51 per cent. SincetheimplementationofICD-10codingbytheGMR(1998),avastmajorityofacutedrugdeathcases havebeenrecordedas‘accidentalpoisoning’(X40 – X49),whichisconsistentwiththenationaldefinition ofanacuteoverdosedeath.Todateover60%overdosecaseshavebeenindexedasfollows:X42.-, T40., T42.-, T43.- . At a more restricted level the code sequence: X42.-, T40.- includes around 70% of all reportedoverdoses. Recent peer reviewed research on fatal drug overdoses (2013-2015) - Abstracts Origer A, Le Bihan E, Baumann M.Socialandeconomicinequalitiesinfatalopiateandcocainerelated overdosesinLuxembourg:Acase-controlstudy.Int J Drug Pol 2014.25:911-915. Abstract Background:Toinvestigatesocialandeconomicinequalitiesinfataloverdosecasesrelatedtoopioidandcocaineuse, recordedinLuxembourgbetween1994and2011.Methods:Cross-examinationofnationaldatafromlawenforcement anddrugusesurveillancesourcesandofforensicevidenceinanestedcase–controlstudydesign.Overdosecaseswere individuallymatchedwithfourcontrols,whenavailable,accordingtosex,yearofbirth,drugadministrationrouteand durationofdruguse.272casesvs1056controlswereanalysed.Conditionallogisticregressionanalysiswasperformed toassesstherespectiveimpactofaseriesofsocioeconomicvariables.Results:Beingprofessionallyactive[OR=0.66 (95% CI 0.45–0.99)], reporting salary as main legal income source [OR = 0.42 (95% CI 0.26–0.67)] and education attainment higher than primary school [OR = 0.50 (95% CI 0.34–0.73)] revealed to be protective factors, whereas the professional status of the father or legal guardian of victims was not significantly associated to fatal overdoses. Conclusions:Socioeconomicinequalitiesindrugusersimpactontheoccurrenceoffataloverdoses.Comparedtotheir peers,usersofillicitdrugswithlowersocioeconomicprofilesshowincreasedoddsofdyingfromoverdose.However,actual andself-referredsocioeconomiccharacteristicsofdrugusers,suchaseducationalattainmentandemployment,mayhave agreaterpredictivevalueofoverdosemortalitythantheparentalsocioeconomicstatus.Education,vocationaltraining andsocio-professionalreintegrationshouldbepartofdrug-relatedmortalitypreventionpolicies. ©2014ElsevierB.V.Allrightsreserved. 63 110 Afulltextversionofthestudycanbedownloadedunder:http://www.relis.lu Abstract Background/Aim:Weanalysedgenderdifferencesinnationalfataloverdose(FOD)casesrelatedtoopiatesandcocaine usebetween1985and2011(n=340).Methods:Cross-examinationofnationaldatafromlawenforcementanddrug usesurveillancesourcesandofforensicevidence.Bivariateandlogisticregressionanalysisofmale/femaledifferences accordingtosociodemographics,forensicevidenceanddrugusetrajectories.Results:Theburdenofdeathscausedby FODonthegeneralnationalmortalitywashigherformen(PMR/100=0.55)comparedwithwomen(PMR/100=0.34). Comparedwiththeirmalepeers,womenwereyoungeratthetimeofdeath(t=3.274;p=0.001)andshowedshorterdrug usecareers(t=2.228;p=0.028).Heroinusewasrecordedmorefrequentlyinfirstdrugoffencesoffemalevictims(AOR =6.59;95%CI2.97-14.63)andaccordingtoforensicevidence,psychotropicprescriptiondrugsweredetectedtoahigher degreeinfemales(AOR=2.019;95%CI1.065-3.827).Conclusion:Thetimewindowbetweentheonsetofillicitdrug useanditsfataloutcomerevealedtobeshorterforwomenversusmenincludedinourstudy.Earlyinterventioninfemale drugusers,routineinvolvementoffirst-linehealthcareprovidersandincreasedattentiontouseofpoly-andpsychotropic prescriptiondrugsmightcontributetopreventprematuredrug-relateddeathandreducegenderdifferences. 2015 Origer A, Lopes da Costa S, Baumann M.OpiateandcocainerelatedfataloverdosesinLuxembourg from1985to2011:Astudyongenderdifferences.OrigerA,LopesdaCostaS,BaumannM.Eur Addict Res. 2014;20(2):87-93.DOI:10.1159/000355170 ©2013S.KargerAG,Basel Origer A., Bucki B., Baumann, M. Socioeconomic inequalities in fatal opiate and cocaine related overdoses:transgenerationalbaggageversusindividualattainments.28thConferenceoftheEHPS“Beyond preventionandintervention:increasingwell-being”,26th–30thAugust,2014,Innsbruck,Austria. Abstract Background:TodeterminesocioeconomicinequalitiesinopioidandcocainerelatedFatalOverDose(FOD)casesand their implications in terms of prevention. Methods Cross-examination of healthcare and forensic data in a nested case-controlstudydesign.FODcases(272)wereindividuallymatchedwith4controls(1,056),accordingtosex,yearof birth,drugadministrationroute,durationofdruguseandcomparedthroughconditionallogisticregression.Findings Employment [OR=0.662(95% CI 0.446–0.985)], legal salary as main income [OR=0.417(95% CI 0.258–0.674)] and educationalattainmenthigherthanprimaryschool[OR=0.501(95%CI0.344-0.729)]revealedtobeprotective,whereas parentalprofessionalstatuswasnotassociatedtoFOD.DiscussionAmongpeers,druguserswithlowersocioeconomic profilesshowincreasedoddsofFOD.However,self-referredsocioeconomiccharacteristics,impactingondailylifequality, suchaseducation,employmentandrevenue,weremorepredictiveofFODthantransgenerationalfactors(e.g.parental socialstatus).Thus,motivationalinterventionsfosteringsocio-professionalintegrationshouldbegivendueattentionin dedicatedharmpreventionpolicies. Origer A, Baumann M.SuicideattemptspriortofataldrugoverdoseinLuxembourgfrom1994to2011. 21stWorldCongressSocialPsychiatry,29June-3July2013,Lisbon,Portugal,Volume:Thebio-psycho-social model:Thefutureofpsychiatry. Abstract Purpose.ToassesstheprevalenceoflifetimesuicideattemptsinopiateandcocainerelatedFatalOverDose(FOD)cases andtoanalyzeassociationsbetweensuicideattemptsanddemographic,socio-economicandsubstanceuseprofilesof FODvictims.Objectives. Thefindingsofthepresentstudymayinspirecareproviderstopayincreasedattentiontofactors influencingsuicidalbehaviorinthecontextofsubstanceuse.Methods. Triangulationofmulti-settingdata.Bivariate statistical analysis and logistic regression analysis. Results. In terms of lifetime prevalence, 16.8% of FOD victims reportedasinglesuicideattempt,37%multipleattemptsand46.2%declarednone.Afteradjustmentforsexandage, FODvictimswhoshowedoneormorelifetimesuicideattemptsweremorelikelytohaveexperiencednon-fataloverdoses [AOR=5.755(95%CI1.633–20.278), p=.006]and(licitorillicit)substanceabuseofoneorbothparents[AOR= 2.859(95%CI1.250–6.539),p=.013].ThegreaterlikelihoodofunmarriedFODvictimstowitnesssuicideattempts observedinbivariateanalysis(x2:4.573;p=.038),comparedwithmarrieddecedents,wasnolongerobservedaftersexageadjustment.Conclusion.Suicideattemptsarefrequentinfataldrugoverdosevictimsandastrongassociationhas beenobservedbetweentheformerandthefrequencyofnon-fataloverdosesexperiencedbydecedentsincludedinour 111 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 sample.Familycontextsmaybeatstakewhenitcomestoexplainthelikelihoodofsuicideattemptsinvictimsoffatal drugoverdoseandincreasedattentionshouldbepaidtofamilyhistoriesinthepreventionofdrugoverdosesandsuicide, andthelinkbetweenboth. Origer A, Baumann M.OpiateandcocainerelatedFatalOverdosesinLuxembourgfrom1985to2011: atime-stratifiedstudy.21thIUHPEWorldConferenceonHealthPromotion.25-29thAugust2013,Pattaya, Thailand,Volume:HealthIssuesandPopulationsinHealthPromotion. Abstract Objective. TodescribetrendsinthenationalprevalenceofFatalOverDose(FOD)casesrelatedtoopiatesandcocaineuse between1985and2011.Toanalyzemale/femaledifferencesinFODvictimsaccordingtovarioustimeperiods.Methods. Triangulationofmultisourcedata,stratifiedaccordingto3successivetimeperiods.Statisticalanalysisofmale/female differencesaccordingtosocio-demographicandforensicdataaswellasdrugusetrajectorieswasperformed.Results. NationalFODprevalencehasbeendecreasingfromthebeginningofthiscenturytoreachahistoricallylowrateof1.71 cases/100,000inhabitantsin2011.TheburdenofdeathscausedbyFODonthegeneralnationalmortalityshowedtobehigher formencomparedwithwomen.Furthermore,thepathwaystowardsaFODrevealedtobedifferentformaleandfemale victimsreferredtovariousaspectsincludingageofdecedents,criminalrecords,drugusetrajectories,drugusepatterns andtheinvolvementofpsychotropicprescriptiondrugs.Conclusions. Thetimewindowforinterventionbetweenthe onsetofdruguseanditspotentialfataloutcomemightbeshorterforwomencomparedwithmen.Earlyinterventionin femaledrugusersandincreasedattentiontopolyandpsychotropicprescriptiondrugsuseshouldbeconsideredinhealth promotionprogrammestoaccelerateaccesstoappropriatetreatment,ifrequired,andeventuallycontributetoprevent prematuredeathandreducegenderinequalities. 112 INTRODUCTION Responsestohealthcorrelatesandconsequencesofdruguseaimatminimisingriskanddamageforthe drugusersandtheirenvironment,andatincreasingindividual/collectiveresources.Theconceptofriskand harmreductionisdirectlylinkedtohealthconsequencesofdruguse,whereasnuisancereductionisseenas acorrelateofthelatter. 2015 7. RESPONSES TO HEALTH CORRELATES AND CONSEQUENCES Healthcareofferstodrugusersareprovidedbyspecialiseddrugcareagenciesaswellasbythegeneral healthcaresystem.Majoreffortshavebeenundertakeninrecentyearstoimprovedataondrugtreatment demandsfromgeneralhealthcareprovidersbyincludingpsychiatricdepartmentsofgeneralhospitalsinthe RELISdatacollectionnetworkandthepilotimplementationofanationalsubstitutiontreatmentregister.In additiontothenationaldrugsurveillancesystemRELIS,thesenewdatasourcesandtoolswillallowtodraw amoreaccuratepictureofinterventionoutcomes. Inadditiontothenational drugs action plan 2015-2019andthenationalHIV/AIDSactionplan20112015(downloadableathttp://www.ms.etat.lu),theMinistryofHealth,jointlywithcompetentfieldactors, iscurrentlyelaboratinganationalactionplanonhepatitis. Asfarasavailabilityofserviceisconcerned,currentlytwonationalagenciesofferharmreductionservices intheCentre,theSouthandtheNorthofthecountryincludingofferssuchasdayandnightshelteranda supervisedinjectionfacility(currentlyonlyinLuxembourgCity).Thegovernmentalprogramme2010-2014 hasforeseenthedecentralisationofrespectiveoffersbyimplementingnewintegratedlowthresholdcentres fordrugaddictsintheSouthofthecountryandbyfurtherdevelopingharmreductionmeasuresintheNorth. AnewharmreductionservicehasopenedintheNorthofthecountryinFebruary2014. Moreover, the governmental programme has foreseen the creation of an integrated low threshold offer (includingasupervisedinjectionroom)alsointhecityofEsch-sur-Alzette.Itsopeningisscheduledfor20162017. PREVENTION OF DRUG-RELATED EMERGENCIES AND REDUCTION OF DRUG RELATED DEATHS Research and recommendations Researchondrug-relateddeathshasbeenfurtherdevelopedandresultedinpeerreviewedinternational publicationsandpresentationsatinternationalconferences: Origer A, Lopes da Costa S, Baumann M.OpiateandcocainerelatedfataloverdosesinLuxembourgfrom 1985to2011:Astudyongenderdifferences.Eur Addict Res.2014;20(2):87-93.DOI:10.1159/000355170 Origer A, Baumann M.OpiateandcocainerelatedFatalOverdosesinLuxembourgfrom1985to2011: atime-stratifiedstudy.21thIUHPEWorldConferenceonHealthPromotion.25-29thAugust2013,Pattaya, Thailand,Volume:HealthIssuesandPopulationsinHealthPromotion. 113 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Origer A, Baumann M.SuicideattemptspriortofataldrugoverdoseinLuxembourgfrom1994to2011. 21stWorldCongressSocialPsychiatry,29June-3July2013,Lisbon,Portugal,Volume:Thebio-psycho-social model:Thefutureofpsychiatry. Origer A., Bucki B., Baumann, M. Socioeconomic inequalities in fatal opiate and cocaine related overdoses:transgenerationalbaggageversusindividualattainments.28thConferenceoftheEHPS“Beyond preventionandintervention:increasingwell-being”,26th–30thAugust,2014,Innsbrück,Austria. Origer A, Le Bihan E, Baumann M. Social and economic inequalities in fatal opiate and cocaine relatedoverdosesinLuxembourg:Acase-controlstudy.Int J Drug Pol 2014.25:911-915.DOI:10.1016/j. drugpo.2014.05.015 Origer A, Le Bihan E, Baumann M (2015) A Social Gradient in Fatal Opioids and Cocaine Related Overdoses?PLoS ONE10(5):e0125568.doi:10.1371/journal.pone.0125568 Drug injection rooms and low-threshold shelters Adrug injection roomisdefinedasafacilityallowingIDUswhomeetcertaincriteriatoinjecttheirown drugsinamedicallysupervisedenvironment.Drugconsumption(user)roomsmeetthesamedefinition;in termsoftargetpopulation;they,however,giveaccesstoIDUsandnonIDUsmeetingtheadmissioncriteria. Theimplementationofafirstdruginjectionroomin2005hastobeseenasapartofabroaderharmand nuisancereductionorientedstrategy.Thenationaldrugactionplanreferstothecreationoflowthreshold emergencyshelterfacilitiesfordrugaddictstobeimplementedregionally. Alow-thresholdemergencycentrefordrugaddicts(ABRIGADO)wasinauguratedinDecember2003and initiallyprovideddaycareandnightshelter.InJuly2005,thefirstsupervisedinjectionroomatnationallevel hasbecomeoperationalandhasbeenintegratedintheABRIGADOcentrewhichfromthenonhasbeen providingtheentirerangeofharmreductionservices,counsellingfacilities,accommodation,washingand launderingfacilities.Itshouldbeaddedthatthenightaccommodationisnottobeseenasapermanent housingfacility;thereisadailyadmissionprocedure.Thetargetpopulationfortheconsumptionroomare primarilyIDUs.Themainobjectiveoftheprojectisthereductionofdrug-relatedharm,nuisances’reduction beingasecondaryobjective.Morepreciselyitaimsatreducingtherisksofoverdoses,infectiousdiseases, publicnuisanceintheneighbourhood,facilitatingcontactmakingwithdifficulttoreachaddicts,provision ofspecialdesignednightshelterfacilitiesandavoidingunnecessaryprisonjourneysovernight.Theproject wasdesignedwiththesupportofthePublicProsecutor’sOfficeandlawenforcementagencies. TheNationalDrugsCoordinator’sofficeelaboratedtheoperationalconceptoftheinjectionroombasedon availableinternationalexperience,literatureandevaluations.Intermsofmanagement,allinvolvedparties meetregularly(called’theMondayround’)toassessthecurrentsituationandemergingproblemsrelatedto thefunctioningoftheconsumptionroom.Incidents,nuisancereports,trends,qualityassurance,workload, technicalimprovementsandsafetyissuesareaddressedbythe‘Mondayround’inordertopromoterapid solutionfindingandcontinuousadaptationtofastchangingclients’profileandconsumepatterns. Table7.1providesaninsightinclients’statisticsoftheABRIGADOservicessincetheiropeningandfor2009 to2014,respectively: 114 Injection Room June 2005 December 2014 2009 2010 2011 2012 2013 2014 1,497 94 108 98 222 139 142 Numberofusersepisodes 257,056 36,558 33,017 26,929 37,004 38,633 40,012 Numberofinjections 291,835 43,871 39,960 31,588 40,234 40,610 42,644 1,990 305 1,685 198 54 144 327 42 285 283 33 250 313 37 276 378 54 324 226 32 194 0 0 0 0 0 0 0 Numberofusercontractssigned Numberofnon-fataloverdoses With loss of consciousness Without loss of consciousness Numberoffataloverdoses Medicalemergencyinterventions Day care Numberofclients Night shelter Numberofdifferentresidents 274 46 33 31 43 42 37 December 2003 – December 2014 2009 2010 2011 2012 2013 2014 521,542 77,333 65,307 62,925 55,622 55,575 59,700 2015 Table 7.1: Clients statistics of ABRIGADO centre services (2005-2014) December 2003 – December 2014 2,562 Source:Abrigado2015 InJanuary2012,AbrigadomovedintonewpremisesandsinceFebruary2012ablowroomhascompleted theexistingoffer.Currentlythenightshelterisopen7daysaweekfrom22:00to08:00withacapacityof 42beds.TheABRIGADOdaycentre,theinjectionroom(7injectiontables)andtheblowingroom(5tables) areopen6daysaweek.ABRIGADOfacilitiesaremostlyusedbymen(85%);themostcommonlyuseddrugs wereheroin(89%),cocaine(4%)orbothofthem(5%).Cocaineusehasobviouslydecreasedin2011and 2012,tostabilisein2013and2014.Concerningtheadministrationmode,54%ofintravenousinjection, 41%ofsmokingand5%ofsnorting.Agecategory25-44years(35%)aremostrepresentative. Nofataloverdosehasoccurreduntiltheendof2014butapproximately1,900overdoseshaveoccurred sincetheopeningoftheinjectionroomandduetotheimmediateinterventionofadhocstaffallvictims couldbeassisted,reanimatedandtheirlivesaved.ThedrugsceneofLuxemburg-Cityadherestoagreat extendtotheABRIGADOconceptwiththepositiveeffectthatpublicnuisancehassignificantlydecreased. TheincreasingnumberofusersattractedbytheABRIGADOservicesposedhoweveraproblemofclients’ management.Therefore,anewcentrewasopenedinthebeginningof2012.Itsimplementationsiteisthe immediatevicinityofthepreviouscentre.Architecturalplanningofthereplacementstructurehasbuiltupon pastexperienceandasuperviseddruginhalationfacility(blowroom)wasincludedintheexistingoffer.The conceptofthedruginjectionroomhasbeenrevisedaccordingly. AsmostrelevantdrugscenesconcentrateintheCityofLuxembourgandinthemaincityintheSouthof thecountry,thegovernmentalprogrammehasforeseenthecreationofanintegratedlowthresholdoffer (includingasupervisedinjectionroom)alsointhecityofEsch-sur-Alzette.Itsopeningisscheduledfor20162017. As far as the northern region of the country is concerned, a needs’ assessment, commissioned by the MinistryofHealth,(JDH,2011)clearlyemphasisedtheneedofatailormadelow-thresholdofferinthe region.However,thetypeofofferneededappearstodifferfromthosecurrentlyexistinginbiggercities suchasLuxembourgandEsch/Alzette.Thedruguserpopulationlivinginthenorthernregionisnotlocally 115 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 concentratedandnon-intravenoususeisreportedtobefarmoreprevalentthanIDU.Largescalesyringes exchangeprogrammesarenotafirstpriorityandmayevenbecounterproductiveinasense.Thissaid, thephenomenaofstigmatisation,isolationandmarginalisationofdrugusersisfarmoreconcerning. Also,thedevelopmentofregionwideoutreachworkinadditiontocommunityoffersappearstobea promisingstrategyforthenorthernregion.Anewlowthresholddaycentre,calledContact-Nord,opened itsdoorsinEttelbrückinFebruary2014.TheContact-Nordcoversthreemainactivityfields:healthand hygieneservices,socialandpsychologicalassistanceandneedleexchangeprogramme. Heroin assisted treatment (HAT) Thefutureimplementationofaheroinassistedtreatmentprogramme,asforeseenbythenationaldrug action plan 2015-2019, should further contribute to reduce drug-related health damage. In 2008, a feasibilitystudyandanoperationalframeworkconcept(Origer,2008),partlyinspiredbytheSwissguidelines on Heroin Assisted Treatment(Bundesamt für Gesundheit,2006)hasbeensubmitted totheMinisterof Health.Themainconclusionsofthesereportscanbefoundinthe2009editionofthepresentreport.It shouldbeunderlinedthattheHATisnotconceptualizedasalowthresholdmeasure.Itisintendedtobe implemented in the broader framework of the national drug substitution treatment strategy with clearly definedmedicalandpsycho-socialcomponents. Adrugscenesurveywasperformedin2008(JDH,2009)inordertoinvestigateperceptionsandopinions regardingtheimplementationofHAT.174drugusersincontactwithdrugcareinstitutionswereinterviewed. 85%ofrespondentsconsiderHATtobeausefulcomplementaryofferforthefollowingreasons(inorder ofimportance):reductionofcriminalityandpettycrime,cleanqualitycontrolledheroin,reductionofdrugrelated mortality, social stabilisation and reduction of harm and health damage. 62% of interviewees declaredthemselvestobepersonallyinterestedtoenterHATifavailable. BythetimeofwritingthegeneralHATconceptwasapprovedandagreementwasreachedwithaspecialised agencyintermsoffuturemanagementoftheprogrammes.Firstresourceshavebeenallocatedalreadyin 2010andstudyvisitstoseveralcountriesrunningHATfacilitieshavebeenundertaken.Nationalexperts havebeenfine-tuningtheexistingconceptinordertooperationalisethisnewtreatmentalternative.Alsothe necessarystepshavebeentakentoadaptnationallegislationandtosettheimport,management,stocking andpreparationproceduresofdiacetylmorphine.AnadequatelocationfortheHATprogrammehasbeen found,whichshouldallowtolaunchthepilotphaseofHATinthecourseof2016. New specialised care structures foreseen in the framework of the 2010-14 action plan ThenewharmreductionagenciesintheSouthandtheNorthofthecountryhavebeendescribedabove. Thelackofnationaldetoxificationcapacitieshasbecomeagrowingprobleminthedrugcarenetworkin recentyears.Accordingtointernationalstandardsthenumberofdetoxificationslotsingeneralhospitals revealedtobesufficient,however,waitinglistsofnewtreatmentdemandersbecameconsistentlylonger partlyduetolongdurationstays.Tofurtherimproveperi-hospitalisationprocedures,itisplannedtoset-upa socalleddiagnostic,referralandfollow-upmechanism(DDOS).Themainideaistoattributeasingle(freely chosenbythetreatmentdemander)referenceperson(socialworker,etc.)toeachtreatmentdemander.This referencepersonorganisesjointlywiththepatientandcareinstitutionstreatmentinterventions,followsup progressionandguaranteesaccesstoafter-careoffers.Thereferencepersonalsorepresentsasinglecontact personforinvolvedcareinstitutions.Asmallscalepilotphaseinvolvingaseriesofspecialisedactorshas beenlaunchedinordertogatherexperienceuntilthenecessaryresourceswillbeallocatedtoimplementa referentsystemnation-wide. 116 PREVENTION AND TREATMENT OF DRUG-RELATED INFECTIOUS DISEASES Prevention 2015 Amobilemedicalcareunit,providingprimarymedicalcaretoclientsofallspecialisedlowthresholdagencies hasbeenlaunchedin2012.Itsobjectiveistoincreaseaccesstomedicalcareandfurtherreferralofhardto reachdrugusingpopulations. Interventionsaimingatthepreventionofdrug-relatedinfectiousdiseasesasforinstanceneedleexchange and substitution programmes have been initiated and developed prior to the set-up of a specific legal framework.Thedruglawamendmentof2001didnotonlyallowmaintainingandtofurtherdeveloping existingharmreductionoffersbutalsosetthefoundationfortheimplementationofnewservicessuchas superviseddruginjectionroomsandmedicallyassistedheroindistributionasforeseenbythenationaldrugs actionplan. Theobjectiveoftheseinterventionsisstraightforward,thatisanoptimisedmanagementofriskfactorsand mental/physicaldamageassociatedtodruguse.Reductionofpublicnuisanceisasecondaryobjective.Both IDUsandnonIDUsaretargetgroupsofHRinterventions.Theinclusionofadruginhalationfacilityinthe ABRIGADOcentreisasoundexampleofthenationalapproach.Furthermoreinfectiousdiseasesprevention shouldnotfocusexclusivelyonIDUsasshowsarecentaction-researchprojectonHIVandhepatitisinfection amongPDU(OrigerAandSchmitJC,2010). The most relevant measure in the field of prevention of infectiousdiseasesindrugusers isthenational needleexchangeprogrammeestablishedin1993andco-ordinatedbyJDH.Inadditiontofreeofcharge needleprovisionbyspecialiseddrugandAIDSagencies,automaticsyringesdispensers/collectorshavebeen placedinthemostappropriatelocationsinfourdifferentcitiesoftheGrandDuchy. Regarding the quantity of distributed syringes, table 7.2 shows that the number of distributed syringes peaked in 2005 and has been significantly decreasing from 2006 onwards, although the return rate remainedconsistentlyhigh.From2011onwardsquantitiesofsyringesdistributedthroughNEPhavebeen decreasing to increase again in 2014. The number of re-collected used syringes exceeded in 2009 the numberofdistributedsyringesviathenationalNEP,(vendingmachinesexcluded),whichsuggeststhatusers alsobringalongsyringesboughtinpharmaciesororiginatingfromvendingmachines,whichisconsideredto beahighlypositiveevolution.From2010to2014,thenumberofcollectedusedsyringeshasbeenranging between90-97%. AccordingtoRELISdata,onethirdofIDUsprocuretheirsyringesprimarilyinpharmacies.Thisproportion hasremainedfairlystableoverrecentyearsanddoesnotdirectlyimpactontrendfiguresfromspecialised needleexchangepoints. 117 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Table 7.2: National needle exchange programme (NEP) 1996-2014 including specialised agencies, vending machines and the supervised injection room Distributed syringes Collected used syringes 1996 76,259 28,646(38%) 1998 109,743 58,886(46%) 2000 189,413 112,625(59%) 2002 254,596 211,621(83%) 2004 435,078 376,491(87%) 2006 332,347 282,909(93%) 2008 259,607 249,400(96%) 2009 289,555 ofwhich45,529via injectionroomand13,353via vendingmachines 301,895(104%) 2010 308,350 ofwhich44,830via injectionroomand8,109via vendingmachines 297,400(96,5%) 2011 246,858ofwhich35,761via injectionroomand5,169via vendingmachines 221,975(90%) 2012 211,439ofwhich29,362via injectionroom and1,336viavendingmachines 201,510(95%) 2013 190,257ofwhich23,631via injectionroom and1,127viavendingmachines 177,790(94%) 2014 250,552ofwhich24,256via injectionroom and358viavendingmachines 235,542(94%) Source: RELIS2015 A syringe and needle exchange programme has started in the national prison (CPL) in August 2005. Demanding inmates are seen by medical staff and if indicated, an initial injection kit containing sterile injectionparaphernaliaishandedout.Sterilereplacementsyringesaredeliveredonpresentationoftheused onesandtheinitialkit.Theprogramisplacedundermedicalsecret. 118 Distributed injection kits Distributed syringes 08/2005 – 12/2006 64 300 2007 24 77 2008 36 178 2009 33 261 2010 34 328 2011 30 440 2012 48 1,383 2013 31 1,726 2014 46 2,101 2015 Table 7.3 Needle exchange programme (NEP) in prison (CPL) 2005-2014 Source: CPL2015 Qualityassuranceandfollow-upofnewinjectionparaphernaliaonthemarketisensuredbyaspecialexpert groupchairedbytheNationalDrugsCoordinator,whointroducednationwidedistributionoflowdeadspace syringesin2014inordertofurtherreducethespreadofblood-borneinfectiousdiseasesviainjectingdrug use. Moreover,outreachinterventionstargetedat(drugusing)sexworkersaimingatestablishingcontactand topreventdisseminationofinfectiousdiseaseshavetakenplace.AccordingtoEMCDDA’skeyindicators and with a view to improve quality of national data on infectious diseases, the NFP has performed an action-research withtheobjectivetoestimateHCVandHIVprevalenceinPDUsandIDUsbasedonmedical diagnosisdata(bloodtesting)andtorecommendtheimplementationofrequiredhealthcaremeasures. The development of new measures to reduce drug-related infectious diseases (e.g. rapid testing, DIMPS, inhalationrooms)largelybuiltandstillbuildsupontherecommendationsofthereferredreportpublished inSeptember2007(Origer&Removille,2007).Thefinalreportmaybedownloadedathttp://www.relis.lu. Severalrelatedarticleshavebeenpublishedinpeer-reviewedjournalssincethen. Counselling and testing The2011-2015HIV/AIDSactionplanproposedtheimplementationoftwonewfreetestingsitesinthe NorthandtheSouthofthecountry,thusregionalisingfreetestingopportunities. IntheframeworkofthepreviousnationalHIV/AIDSactionplan2006-2010amobileinterventionfacility forsexualhealthpromotion(DIMPS)hasbeensetupjointlybytheMinistryofHealth,HIVBerôdung(RED CROSS) and the CHL. DIMPS may be described as an outreach offer for specific target populations and vulnerablegroupsaimingtoaccessdifficult-to-reachpopulationsandprovidepreventioncounsellingand infectiousdiseasetestingonsite.Theproject,startedinMay2009,providesfreerapidtestingofHIVand hepatitisandoutreachcounsellingtargetingamongothersdrugusers,sexworkersandasylumseekers.In 2014,519counsellingepisodeshavebeenreportedbyinvolvingatotalof478clients.515HIV,137HCV and83syphilisrapidtestshavebeenperformedduring2014. Finally, it should be stressed that HAV, HBV, HCV and HIV testing and vaccination for HAV and HBV is proposedtoeachpersonenteringprisonbyintramurosmedicalstaff. 119 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Infectious diseases treatment Thenationalserviceforinfectiousdiseases,implementedwithintheCHL,providesspecialisedtreatmentof infectiousdiseases.Incasethepatienthasnoornovalidhealthinsurance,treatmentcostsmaybecovered bystate. Since2009,aspecialisedmedicaldepartmentfortransmittablediseases(COMATEP)isoperationalwithin theCPL(prison). Interventions related to psychiatric co-morbidity ThenumberofconfirmedDDpatientsisestimatedat40-50people(adults)nation-wide.Thesepatients showexplicitpsychiatricdisorders,areoftensociallydisintegratedandneedindividualfollowupalthough theytendnottobeattractedbyexistingcareoffers.Furthermore,thestaffofspecialisedassociationsmust be specifically trained to take care of DD clients. Instead of creating a specialised and centralised care infrastructure,abetterfollow-upofpatientswithinexistingoutpatientservicesisneededinthefirstplace, knowingthatthereferredclientsonlyintegratewithdifficultiesinstructureswithcompulsoryresidential character.The‘TherapeuticChain’expertgrouphasrecommendedinthiscontexttofine-tunetheconcept ofsupervised/accompaniedhousinginordertomovetowardsacasemanagementapproachinaprivate andindividualisedenvironment,knowingthatDDpatientsoftenhavedifficultiestoadapttocommunity orientedsettingsandoffers. RESPONSES TO OTHER HEALTH CORRELATES AMONG DRUG USERS Somatic co-morbidity and general health related treatment AccordingtolongitudinalRELISdata,thegeneralstateofhealthofdrugusersappearstohaveimproved duringthelastdecade,whichcouldbepartlyduetothesignificantdevelopmentofharmreductionand treatmentreferraloffers. Thevastmajorityofspecialisedout-andinpatientandlowthresholddrugcarefacilitiesincludemedicalor paramedicalcareintheirserviceprovision.Ifneeded,patientsarereferredtospecialisedtreatment.Related costsarecoveredbyhealthinsuranceschemesorbytheMinistryofHealthincasethepatienthasnovalid insurance. Intheframeworkofthedrugsactionplan2010–2014,amobilemedicalserviceprovidingfreeandonsite medicalcaretodrugusersindependentlyoftheinstitutionalsettingtheyarein(excepthospitals)hasbeen implemented. Non-fatal drug-related emergencies Nospecificdataondrug-relatedemergenciesarecurrentlyavailableatthenationallevel.Figure7.1refersto RELISdataonpreviousnon-fatalandmedicallyassisteddrugoverdoseself-reportedbyPDU.Theproportion ofindexeddrugusersreportingatleastoneoverdose(asdefined)appearstobedecreasingfrom2008to 2012.Thesefigureshavetobeseeninthelightofthesignificantnumberofoverdoseincidentsthathave occurredinthenationalsuperviseddruginjectionroomwithoutfatalconsequences,duetoimmediateassistance(around1,900). 120 80 Non fatal drug overdoses in RELIS respondents (2004-2014) (valid %) One More than one None 60 60 38 40 40 20 22 39 45 37 56 20 27 35 28 17 14 2010 (161) 20111 (232) 11 58 53 43 29 16 64 58 30 25 11 12 12 2012 20 2 (331) 20133 (259) 20 20 4 (251) 2014 2015 Fig. 7.1: 0 2004 (320) 2006 (311) 2008 (260) 2009 (231) Source:RELIS2015 Prevention and reduction of driving accidents related to drug use Thelawof18September2007 modifiesthenationaltrafficcodeandintroducestestingofillicitdrugusein vehicledrivers.Thehomologationofrespectiveroadsidetestshasbeenregulatedbyagrand-ducaldecree ofNovember18,2011.Formoredetailsonthenewlegislationpleaserefertochapter1(laws). Interventions concerning pregnancies and children born to drug users In the context of the development of social paediatrics at national level, child care professionals and paediatricianscallfortheimplementationofspecialisedcarestructuresforchildrenatrisk.Theapproachof socialpaediatricsconsidersachildinhisglobalcontextincludingphysical,psychological,socialandcultural health,familyandenvironmentalcontextandpromotescoordinationandcollaborationbetweendifferent socialandmedicalservices. Duetotheimprovementof,andthebetteraccesstodrug-relatedtreatmentandespeciallythespreadof substitutiontreatment,thebirthrateindrugusershasincreasedoverrecentyears.Thisevolutionhasbeen leadingtothefirstparentalprojectlaunchedbyJDHin2003withtheaimtoprovidepsycho-socialaidto drug-dependantparentsandtheirchildren.Theprimaryobjectiveoftheprojectistoensuresecurityand well-beingtochildrenandtostrengthenparents’educativeabilities.Thislongtermprojectisbasedupon contractual commitments, co-intervention, home visits and functions in close collaboration with involved services.Anessentialpartoftheprojectconstitutestheoutreachwork.Meetingsandinterviewsareheld withinthenaturalenvironmentofthefamily(athome). Thenewnational drugs action plan 2015-2019furtherfocussesonnewmeasuresorientedtowards pregnantdrugusingwomenandchildrenofdrugusingparents. 121 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 8. SOCIAL CORRELATES AND SOCIAL REINTEGRATION INTRODUCTION SocialcorrelatesofdruguseinvolveJustice,HealthandEducationalcompetences.TheMinistryofHealthand theMinistryofFamilyandofIntegrationbothintervenebyfinancingmeasurestoreducesocialconsequences rangingfromearlydetectionofdrugusetosocial-professionalrehabilitationinterventions.Thereductionof drug-relatedcrimeinvolvestheMinistryofJustice,focusesonsupplyreductionactivitiesandtheMinistryof Healthimplementsmeasurestargetingsocio-professionalre-integrationaimingatreducingdailyexpenses anddepthsofdrugaddictsandthustheprevalenceofacquisitioncrimes. SOCIAL EXCLUSION AND DRUG USE Social exclusion among drug users Thequestionwhethersubstanceabuseleadstosocialdegradationandexclusionorsocialfactors(e.g.family situation,poverty,loweducationorjobperspectives)leadindividualstosubstanceuseisanunanswered one.Obviouslyavastmajorityofhomelessandsociallyexcludedpeoplealsopresenttovariousextends licitand/orillicitsubstanceabuse.Also,economicparameterstendtohaveatangibleimpactondruguse prevalenceandpatternsaswellasonthelevelofacceptanceandperceptionofdrugaddictsbythegeneral population. A sound example of how social rejection and drug abuse are dynamically linked might be seen in the nationalresultsofthe4thwaveoftheEuropeanValuesStudy64.55%ofnationalrespondents(N:1,610) describeddrugaddictsasmostunwantedneighbours.In1999drugaddictsoccupiedthesecondposition (43%). Also, providing medical and psychological care to drug dependent persons is not enough as the social situationofthesepeopleneedstobeimprovedbeforesustainedoutputsindrugtreatmentisexpectable. Thissaid,thenationalstrategyofcareforsociallyexcludedpeopleisbasedontheprincipleofprogressive reintegration through capacity building and the improvement of the social abilities and environment. Associations as ‘Stëmm vun der Strooss’ (Street voice) and Quai 57, financed by the Ministry of Health, try to involve the target population again in active life by providing a safe and common environment andrespectingindividualcapacitiesandresourcesbyapplyingcasemanagementmethodologiesfurther describedbelow. 64 EVSFoundation/TilburgUniversity:EuropeanValuesStudy2008,4thwave,IntegratedDataset.GESISCologne,Germany,ZA4800 DataFileVersion1.0.0(2010-06-30)DOI:10.4232/1.10059. 122 Drug use among socially excluded groups Accordingtoestimationsfrom2007,around700personsarecurrentlyhomelessintheGrandDuchyof Luxembourg65.Thestudyreportedaproportionof54%malesand46%femalesandarelativelyyoungage ofhomelesspopulation.Halfofthepopulationofhomelesspeopleisaged18to34yearsandonly9%are agedmorethan55years. Morespecifically,housingstatusofregistereddrugusershasmarkedlyimprovedduringrecentyearsandtends tostabiliseoverthelastyears.Since1995,theproportionofpersonsdisposingofastableaccommodation hasmorethandoubled.Currently72percentofPDUreportastablehousingsituation(RELIS2015).This positiveevolutionmaybelinkedtoanincreasedawarenessofthehousingproblemandtheset-upofnew housingnetworksforsociallydeprivedpeoplebytheMinistryofHealthandspecialisedagencies.Recent figuresalsotendtoconfirmthatalthoughspecialisedaccommodationoffershavebeenfurtherdeveloped, thecurrenteconomicsituationhascreatedanevenhigherdemandforthistypeofhousing. Fig. 8.1 2015 Homelessness Last known housing situation of problem drug users. 2009-2014 (% valid) 80 70 60 50 40 30 20 10 0 2009 (345) 2010 (259) 2011 (236) 2012 (330) 2013 (284) 2014 (261) 64 62 70 70 68 72 Unstable accommodation 15 15 7,5 9 9 9 Stable accommodation In institution 6 5 7,5 4 6 6 Other 15 18 15 17 17 13 Source: RELIS2015 Youngstersagedlessthan25andlivinginthestreetarereferredtoasaquitenewphenomenon.Societal changesastheincreaseofmonoparentalfamilies,anincreasednumberofdivorces,increasingyouthjobless ratesandthenecessitytoworkforeconomicreasonsforthetwopartnersofaparentalcouplearelikelyto haveanegativeimpactonyoungster’spsychologicaldevelopment,educationandperspectives. 65 Centred’EtudesdePopulations,dePauvretéetdePolitiquesSocio-Economiques(2007).L’exclusionliéeaulogementdespersonnes prisesenchargeparlescentresdejour,lesfoyersdenuit,lescentresd’accueiletleslogementsencadrés.Luxembourg 123 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Unemployment Theunemployment rate (60%)showsaweakdecreasebetween2011and2014,However,anin-depth analysisshowsthattheproportionofactiverespondentsreportingastablejobsituation(e.g.longterm contract; 14%) has sensibly decreased over the 5 last years, which might be partly due to the ongoing economiccrisis. Fig. 8.2 Unemployment rate in problem drug users (1996 - 2014) 80 60 40 20 0 STATEC TA TATEC (2004) Unemployed 4.2 1996 (318) 1998 (175) 2000 (287) 2002 (422) 2004 (353) 2006 (672) 2008 (542) 2009 (334) 2010 (254) 2011 (238) 2012 (334) 2013 (286) 2014 (270) 29 46 65 50 45 72 63 64 69 67 63 61 60 Source: RELIS2015Remark:STATEC:StatisticalDepartmentofState–Unemploymentrateinactivegeneralpopulation. Dataonrevenuesconfirmobservedtrendsinoccupationalstatus: - decreaseofsocialdependenceassociatedtoastable financial autonomy.TheGuaranteedMinimum IncomeconstitutestheprimarysourceofrevenueofPDU. - illegalactivitiesasmainrevenue havewitnessedanongoingdownwardtrendsince1995,although theyhavegainedinimportancein2009,2011,and2012. Fig. 8.3 Primary source of income of problem drug users (1995 - 2014) 75 50 25 0 1995 (407) 1997 (243) 1999 (321) 2001 (422) 2003 (439) Autonomy 35 34 29 30 29 Social welfare 42 52 60 61 65 Illegal income 23 13 10 8 Other 0 1 1 1 Source: RELIS2015 124 2005 (347) 2007 (367) 2008 (315) 2009 (336) 2010 (252) 2011 (237) 28 28 23 66 68 74 6 4 4 1 1 1 2012 (330) 2013 (283) 2014 (268) 22.5 17 66 71.5 20.5 24 21.9 19.4 64.6 58.4 63.6 3 8.5 69 6.5 8.4 10 8.8 7.5 0 3 5 6.5 7.6 5.7 4.1 The study of ‘School leave in Luxembourg’66 (2006) surveyed a population of 37,347 secondary school studentsduring1stNovember2004and30April2006.Atotalof2,422studentsleftschoolwithouta professional certification (temporary stay offs from school have also been taken into consideration). The studyreferstoaproportionof6.5%of‘schoolleavers’.Thisproportionfigures3.6%ifoneisconsideringthe totalnumberofstudentshavingbeenreachedbutdidnotreintegratedaschoolinLuxembourg.Concerning thiscategoryofschoolleavers,composedofstudentsattendingcoursesabroad,beingemployed,following professionalinsertionmeasuresandthosewithoutoccupation(N=1,357),thesituationwasasfollows:41.2% ofstudentswhodroppedschoolhaveintegratedthejobmarket(workorprofessionalinsertionmeasure), 39.8%didn’tworknorwenttoschooland19%attendedschoolcoursesabroad.Ingeneral,boys,youngsters fromabroadandagedmorethan15years(ageofschoolobligationin2006)aremorevulnerabletothe riskofearlyschoolleave. Fig. 8.4 2015 School drop out Educational level of RELIS respondents (2014) 100 80 60 40 20 0 Concluded levels (N: 208) Non-concluded levels (N: 143) Primary school 74 5 Secondary school 25 90 High school 1 5 Source: RELIS2015 Regarding PDU, the educational level of the latter, low and mostly incomplete, has been showing a creepingdeteriorationsince1999accordingtobaselinedatafromRELIS.However,anincreasingproportion ofrespondentsstartsecondaryschoolwithoutbringingtheirstudiestoterm.Theaverageageattheendof studiesshowsaglobalincreasingtendencyoverthelast4yearsandcurrentlysituatesat17.8years.Lower levelsareparticularlyobservedasregardsacquiredsecondaryandhighschooldiploma. Financial problems TheRMG(GuaranteedMinimumIncome;35%)andthepropersalary(19%)representthemainincome sourcesofPDU.Between1997and2014,strongvariationshavebeenobservedinrelationwiththesetwo revenues.RMGasaprimarysourceofrevenuehasknownaremarkableincreasefrom1997onwards.Ithas decreasedin2012and2013,andincreasedagainin2014.Thepropersalary,whichdecreasedduringthe lastyearshasincreasedin2011and2012,todecreaseagainin2013and2014.Moneyprovidedbyparents asfirstsourceofincomehasincreasedin2013,andremainedstablein2014(18%in1997;14%in2013; 14%in2014)afteralongperiodofdecrease. 66 Ministèredel’EducationnationaleetdelaFormationprofessionnelle(2006).LedécrochagescolaireauLuxembourg.Luxembourg 125 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Concerningsecondaryincomesources,34%referredto‘illegalactivities’67and28%wereprovidedmoney byparents. In2014,thedegreeofsocialdependenceshowsanincreasingtendency(69%in2014–63.6%in2013 –58.4%in2012–42%in1995)whichcorrelateswithaninversetrendasfarasfinancialautonomyis concerned. SOCIAL REINTEGRATION Housing Socialreintegrationmeasures,andinparticularimprovementanddiversificationofhousingoffersfordrug addicts,havebeenoneoftheprioritiesofthe2000-2004nationaldrugsactionplan.The2005-2009drugs actionplanhasforeseentheexpansionofexistingprojectsandtheimplementationofnewdecentralised reintegration measures based on the previously described principle of progressive reintegration through capacitybuildingandtheimprovementofthesocialabilitiesandenvironment. Intheframeworkofthe2000-2004actionplan,theMinistryofHealth,jointlywiththeCityofLuxembourg openedanight shelter (called‘Nuetseil’) for drug addictsinDecember2003whichhasevolvedinan integratedlowthresholdcarecentrefordrugaddicts(ABRIGADO)includingdayandnightshelteroffers, accommodationandasuperviseddruginjectionfacility. A project called ‘Les Niches’functionsasasocialrealestateagencyfordrugaddicts.Around55flatsand apartmentsarerentedbyadrug-counsellingcentreandprovidedtodrugaddictsinneedbymeansoftailor maderentingcontracts.Oneofthemediumtermaimsoftheprojectistoallowdemandingdrugaddicts totakeovertherentingcontractonbasisoftheirownfinancialmeansandthusdisposeautonomouslyof astableaccommodation.TheprojectisjointlyfinancedbytheMinistryofHealth,NationalFundagainst drugtrafficking,andtheCityofLuxembourg(VDL).ThevastmajorityofrealestatesarerentedbytheJDH fromprivateproprietors;theremainingonesbelongtothenationalhousingFund(Fondsdelogement)or tomunicipalities. Anetworkofsupervised housing facilitiesforspecifictargetgroupsasforinstancepregnantwomen, drugaddictedcouples,treatmentdemandersonmethadoneareoperationalsinceSeptember2002andare situatedinthevicinityofthemaincentreinordertotakeadvantageoftrainingandsocialreintegration facilitiesofferedbytheCTM.TheCTMalsoofferseducationalaidinseveraldomainsaswellasprofessional trainingopportunities.25personsbenefitfromthereferredofferthatbuildsuponapartmentsandhouses situatedinvariousmunicipalities. ThepreviouslyreferredtoNGOStëmmvunnderStroossalsomanagesaround30supervisedlodgings. Inallprogrammes,apartmentsaresubcontractedbytheNGO/agencytoclientsandtheformerareliableto theactualproprietors.Thisavoidsimmediateconflictsituationsincaseaclienthastransitionalproblemsto paythemonthlyrent.Rentsarealsotypicallylowerthangeneralrealestatemarketprices.Intheframework of these programmes, beneficiaries are also offered the possibility of financial management and followup in case of debts for instance. In the medium and long term, residents may be able to sign a proper rental contract or move to an autonomous housing. The supervised housing projects have allowed thus fartostabilisemostofbeneficiaries,toavoidrelapseandtocreatethenecessaryconditionsforasocioprofessional(re)-integration. 67 126 Mainly selling of drugs. Aimingprofessionalreintegration,aseriesofresidentialdrugcarecentresofferoralandwrittenlanguage coursesinordertoprovideclientswithbasiclanguageskills(ifnecessary)ortoimprovetheirwritingskills. ‘D’StëmmvunderStrooss’association(‘Streetvoice’association)primarilytakescareofhomelesspeople providingthemwithlowthresholdfacilitiesandofferingsocialandprofessionalreintegrationactivitiessuch asliteracycourses(providedbyvolunteers)andworkshops(injournalismandradiobroadcasting)heldby professionals.‘Thevoice’(‘d’Stëmm’)monthlybroadcastsaoneandahalf-hourprogrammeonalocalradio. Providingclientswiththeopportunitytowidentheirknowledgeandintroducingthemtodifferentorless commonprofessionshasledtoafairsuccessintermsofinterestofparticipantsandretentionrates. 2015 Education, training Employment Anotherreintegrationprojectrunbythereferredassociationisthetherapeuticwritingboard,wherehomeless people are given the opportunity to editing, printing, publishing and distributing an in house magazine. This activity is supervised by professionals (one educator and one pedagogue). Addressing socialmattersissupposedtohelpclientstoregainasenseofresponsibilityandtoincreasethelevelof acceptabilityinthegeneralpublic(therapeuticaim).Anotheraimissensitizingawiderpublicandhelping homelesspeoplefamiliarizewithnewtechnologies.PDUconstituteasignificantfractionoftheirclients. Additionallyclientsareofferedtaskandjobopportunitiesinthelaundryservicecalled‘Schweessdrëps’(Drop of sweat)whichcoverstheSouthofthecountryandisspecialisedinwashingsportsteams’uniforms.Forthe lastyears,2socialworkers,3educatorand30clientshavebeenworkingonaveragefor280sportsteams. Besidesthesetwomainwork-opportunities,theservicealsooffersatherapeuticworkshopcalled‘Dressed for success’.Theservicehasbeenmanagedby2clients(offeringthemajobopportunityandresponsibility). Theirmaintaskwastoorganise(collect,wash,store,etc.)clothesofferedbydonors. Anewoccupationalprojectrunbythe‘Streetvoice’(‘StëmmvunderStrooss’)associationfurtherclosing thegapinoccupationaloffersfordrugaddictsatthenationallevelhasopenedinthebeginningof2014. Theresidentialcentreofferstemporaryaccommodationanddayjobsforhomelessandaddictedpeoplein aruralsetting. The national referent system The national drug action plan foresees the creation of a national ‘referentsystem’ for drug addicted personsinneedofcare.Therationaleofthisprojectisstraightforwardandstemsfromtheobservationthat drugrelatedcareandrehabilitationoffersarediverseandagivenpersonentersincontactwithseveral nationalandtransbordercareprovidersandlawenforcementauthoritiesinthecourseoftheirtreatmentand (re)-integrationhistory.Oftenthelinkbetweenthesedifferentstagesandinstitutionscouldbeimprovedifa designatedreferentcouldfollow-uppatientsindividuallyandcentraliseinformationonthepatientandhis/ hertreatmenthistory.Soundexamplesoftheusefulnessofthissystemarethepreparationofreleasefrom prison(e.g.continuationofsubstitutiontreatmentorhousingfinding),referraltoanationalcareproviderfor patientsinresidentialtreatmentabroadorpreparationofadmissiontotherapyfollowingadetoxification treatmentinhospital. 127 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 9. DRUG-RELATED CRIME, PREVENTION OF DRUG-RELATED CRIME AND PRISON INTRODUCTION ThemainsourceofinformationofthispartofthereportistheJudicialPoliceService(SPJ)inLuxembourg. DuetoobviousdisparitiesattheEuropeanlevelintermsofconceptdefinitionsinthefieldoflawenforcement data,therespectivenationalterminologyshouldbeclarified: - ‘Interpellation’ (Eng. Interpellation/peremptory questioning, to call on): Interventionoflawenforcementagentsbasedonreasonablesuspicion.The‘interpellated’ personisheard andapolicerecordoccurs.Atthislevel,however,thereisnonotificationtothePublicProsecutorandno mentioninthejudicialrecord. -Theterm‘prévenus’(interpellated/indictedperson): Referstopersonswhohavebeenapprehendedbylegalenforcementagentsforallegedoffencesagainstthe nationaldruglaw(oragainstlawingeneral). - ‘Arrestation’ (Eng. Arrest) : Interpellationfollowedbyadeprivationoflibertyandnotificationtotheattorneyatlaw.Thepreliminary examination(instruction)referstothesubsequentjudicialprocedurethatleadstopublicaudience,which claimsthesentence. - ‘Condamnation’ (Eng. Conviction) : Judgementbywhichtheaccusedpersonisfoundguilty. - ‘Détention’ (Eng. Imprisonment) : Deprivationofliberty.Distinctionismadebetweenprotectivecustody(priortothejudgement)andregular detention(followingconviction). DRUG-RELATED CRIME TheNFPprocessesanonymousnation-widedataondrug-relatedoffencesprovidedbythelawenforcement agenciesrequiredfortheeditingofthenationalreportondrugsandtofulfilinternationaldatarequirements (EMCDDA,UNODC,etc.). 128 As can be seen in tables 9.1, the total number of arrests for drug-related offences (167) has increased discontinuouslyuntil2010andstabilisedthereon.Heroinwasthemostfrequentsubstanceinvolvedindrugrelatedarrests.Heroinisthemainsubstanceinvolvedinthosearrests,followedbycocaine. Table 9.1 Arrests by type of reporting institution (1995-2015) ARRESTS Year 95 97 99 S.P.J. 27 25 27 7 25 38 26 39 49 32 20 15 33 6 11 3 Gendarmerie 8 15 15 / / / / / / / / / / / / / Police 32 32 32 45 82 103 94 124 79 102 92 166 97 119 128 138 Customs 61 82 34 40 28 37 35 62 41 54 33 48 51 44 36 26 Total 128 154 108 92 135 178 155 225 226 188 145 229 181 169 175 167 2001 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Drug law offences Source: RELIS2015 Thenumberofpolicerecordsforpresumedoffencesagainstthemodified1973druglaw(code:DELIT-STUP), stablebetween1996and1998,showedanimportantincreasefrom1998to2003(825to1,660)andhas beenstabilisingsincethen.In2009and2010,however,thenumberofreferredpolicerecordsincreased anew(2010:2,546records,2014:2,816). From2003to2008,oneobservesasignificantdecreaseindruglawoffenders,butobviouslyanewincrease in2009(1,963)and2010(2,530).In2011and2012adecreaseisobservedasregardsthenumberofdrug lawoffenders(1,782)aswellasforthenumberofarrests(169).In2013,both(numberofoffenders:2,066 andnumberofarrests:175)showedanincrease.In2014,thenumberofoffendersincreasedagain(2,792 offenders,and167arrests). Table 9.2 records the total number of law enforcement interventions and number of ‘prévenus’ at the nationallevelensuredbyrespectivelawenforcementactorsthataretheSpecialisedDrugDepartmentofthe JudicialPolice(SPJ),PoliceandBoardofCustomsfrom1995to2014. Table 9.2: Number of national law enforcement interventions (1995-2014) DRUG LAW ENFORCEMENT RECORDS Year 95 97 99 2001 2003 2006 2007 2008 2009 2010 2011 2012 2013 2014 S.P.J. 123 137 343 216 239 190 177 110 121 134 165 44 17 9 Gendarmerie 198 255 782 / / / / / / / / / / / 1,969 1,643 1,526 1,849 232 203 Police 68 Customs 69 Total 199 177 189 1,126 1,326 824 998 881 1,465 244 236 173 113 95 186 197 228 328 764 805 1,487 1,455 1,660 1,200 1,286 1,219 443 1,914 2,546 477 2,651 156 2,225 1,802 2,069 2,816 68 ThegeneralactivityreportoftheGovernmentGrand-DuchyofLuxembourgcanbedownloadedfrom:http://www.gouvernement.lu/ publications/informations_gouvernementales/rapports_activite/index.html 69 The original report can be downloaded from : http://www.gouvernement.lu/publications/informations_gouvernementales/rapports_activite/index.html 129 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition OFFENDERS Year 1995 1997 1999 2001 2003 2006 2007 2008 2009 2010 2011 2012 2013 2014 S.P.J. 152 182 434 321 369 248 203 128 121 131 164 44 17 9 Gendarmerie 319 335 916 / / / / / / / / / / / Police 70 371 280 283 421 408 306 Customs 71 Total 1,272 1,753 1,007 182 148 320 1,160 324 1,009 1,459 1,960 1,632 350 325 439 407 1,517 1,846 2,623 221 200 471 1,263 1,205 1,939 1,776 2,270 1,575 1,687 1,487 1,963 2,530 2,210 1,782 2,066 2,792 Source:SpecialisedDrugDepartmentoftheJudicialPolice2015 7071 Thepopulationofdruglawoffendersiscomposedof86%males;aproportionthathasbeenvaryingbetween 80%and90%duringthepastdecade.Since1997,non-natives (48%in2014)havebeenrepresenting themajorityofdruglawoffenders.In2010,thepercentageofminorsamongdruglawoffendersincreased (9.2%in2010)andthisincreaseisconfirmedbythemostrecentfigures(8.5%in2014). Table 9.3 : Socio demographic data on drug law offenders ( ‘prévenus’) (1990-2014) AGE 0-14 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 27 21 15-19 320 169 270 249 6 1 3 7 415 413 11 15 41 20-24 527 403 447 321 519 497 566 650 557 24 9 8 399 647 602 334 436 279 510 617 415 11 318 8 26 19 23 14 25-29 371 309 304 220 448 354 299 388 375 278 345 323 321 274 159 186 191 35-39 52 65 ≥ 40 46 21 50 20 421 551 419 187 269 208 194 219 254 250 230 188 216 205 257 318 301 273 80 76 131 113 139 177 162 190 174 136 162 134 157 233 175 160 181 253 42 78 84 108 113 82 174 126 153 181 165 129 189 209 197 181 209 347 31 32 46 44 55 40 106 95 70 43 14 19 15 16 32 3 303 363 494 319 470 4 9 TOTAL 1,531 1,174 1,368 1,170 1,939 1,758 1,776 2,218 2,271 1,808 2,034 1,575 1,687 1,487 1,963 2,530 2,210 1,782 2,066 2,792 Male 1,248 938 1,138 958 1,658 1,415 1,546 1,905 1,935 1,581 1,751 1,319 1,484 1,263 1,645 2,144 1,900 1,562 1,773 2,428 Female 256 209 173 193 248 241 215 Gender unknown 27 57 19 15 27 33 44 292 288 21 48 181 237 218 190 206 283 367 301 220 286 364 49 46 38 13 18 35 19 9 0 7 Source: SpecialisedDrugDepartmentoftheJudicialPolice2015 70 ThegeneralactivityreportoftheGovernmentGrand-DuchyofLuxembourgcanbedownloadedfrom:http://www.gouvernement.lu/ publications/informations_gouvernementales/rapports_activite/index.html 71 The original report can be downloaded from : http://www.gouvernement.lu/publications/informations_gouvernementales/rapports_activite/index.html 130 23 480 436 594 677 602 422 545 580 30-34 unknown 7 282 323 484 494 404 545 616 0 Table 9.4: Distribution of drug law offenders (‘prévenus’) according to first offence and underage status (1992-2014) First offenders 697 382 508 422 608 828 585 657 471 533 546 667 949 913 720 854 1,066 Offenders underage 96 57 102 79 154 145 103 86 72 80 83 86 178 141 145 171 237 TOTAL (‘Prévenus’) 1,531 1,174 1,368 1,170 1,758 2,218 1,808 2,034 1,575 1,687 1,487 1,963 2,530 2,210 1,782 2,066 2,792 Source: SpecialisedDrugDepartmentoftheJudicialPolice(DataformattedbyNFP)2015 Table 9.5 Distribution (%) of first drug law offenders (use and use/traffic) according to substance involved ad minima (1992-2014) 2015 1992 1994 1996 1998 2000 2002 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2013 2014 High risk substance involved ad minima Heroin 70 70 65 Cocaine 27 18 Amphetamines 2 7 Type‘Ecstasy‘ 0.5 Illicitlyacquiredmedicaments Substitutionsubstances 59 67 51 43 57 57 60 55 40 28 18 16 19 28 52 35 31 34 35 53 61 6 10 5 5 1 2 5 2 4 5 3 4 11 14 6 15 3 3 6 2 3 1 2 0.5 1 0 1 3 0 1 3 1 2 0 0 5 0 0 0 0 0 1 0 0 0 0 3 1 1 Source: SpecialisedDrugDepartmentoftheJudicialPolice(DataformattedbyNFP)2015 Other drug-related crime Theroutinedataprotocolofthenationaldrugmonitoringsystem(RELIS)includesaseriesofdrugrelatedoffences’items:Thefollowingresultssummarisethesituationobservedin2014: - 83% of drug users indexed72 by specialised health care institutions have already been in conflict with law enforcement agenciesduringlifetime. - 59%ofthetotalPDUpopulationshowmultiplelawenforcementcontacts(increase). - Theproportionofrecordsforotherreasonsthanpresumedoffencesagainstthedruglaw(e.g. petty crime suchascriminalitylinkedtodrugsupplyorfights)hasbeendecreasingsince1997 (38%)andhasbeenfairlystableinrecentyears,exceptfor2010,wheredataon‘interpellations’ forotherreasonsreportedanimportantincrease(2006:34%,2009:35%,2010:65%).After 2010, the proportion of records for other reasons decreased (2011: 36%, 2012: 28%, 2013: 21%,and2014:30%). - 63%(68%)ofindexedPDUhavealreadyservedatleastoneprison sentenceduringlifetime. TheproportionofPDUhavingservedmorethanoneprisonsentenceatthetimeofreporting (40%)showsaslightdecrease,afteranincreaseoverthelastyears. 72 PersonswhohavebeenindexedbytheRELISnetworkduringareportingyear. 131 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition PREVENTION OF DRUG-RELATED CRIME Inrecentyears,theinvolvementofmajorcitiesinthemanagementofdrug-relatedproblemsandnuisances hasdeveloped.So-calledmunicipal‘preventioncommittees’thatincludelocalauthorities,policeforcesand specialisedNGOsareinplace.ThesetupofthefirstnationaldruginjectionroominLuxembourgCityobviously enhancedtheinvolvementofmunicipalauthorities.TheMinistryofHealthcreatedamanagementgroup thatismandatedtofollowupdevelopmentswithregardtotheinjectionroomandtoreactprecociouslyto emergingproblems.Thenationalactionplanclearlyemphasisestheimportanceofavisibleinvolvementof majorcitiesinthemanagementofpublicsafetyandorder,urbannuisanceandhygieneproblemsrelatedto drugstoguaranteethenecessarydecentralisationofDRoffersandSRinterventions. Asfaraspreventivemeasurestargetingyoungstersareconcerned,amechanismhasbeenputinplacein 1996aimingatunderageandjuveniledruguseoffendersandinordertopreventrecidivism.TheIMPULS project(IMPULS-Aideauxjeunesconsommateursdedrogues-SolidaritéJeunesa.s.b.l.)isfinancedbythe MinistryofHealthandintervenesincaseaminorofageandyoungsterhavebeenrunninginconflictwith lawenforcementforceswithrespecttoadrug-relatedoffence.InthisrespecttheYouthSolidarityteammay beconsideredasacrisissituationmanager,offeringtheirservicestodrugoffendersreferredbyjudicialand penalinstitutions.Theavailableservicesarefreeofcharge. The intervention team, in direct collaboration with Youth magistrates and competent law enforcement actors,offersalargevarietyofserviceswiththeprimaryaimtopreventminorageddrugoffenderstoenter inthecriminaljusticesystem.Interventionsarebasedonaholisticapproachoftheproblem,includingthe involvedpersonhim/herselfandhis/herfamily.YouthSolidaritydirectlyreportsoninterventionprogressto thedemandingauthority.Clientstatisticsshowanincreasingdemandforthiskindofinterventionfromboth thecriminaljusticesystemandthesocialorientedinstitutions. Table 9.6: Clients core statistics IMPULS 2000 – 2014 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Number of episodes 132 195 231 267 249 322 352 357 432 461 2011 2012 2013 2014 416 489 490 574 Referral from the criminal Justice system 41.4% 44.1% 44.2% 37.2% Gender distribution Female Male 34.1% 32.3% 34.1% 31.6% 31.9% 31.3% 30.1% 24.4% 30.5% 24.3% 29.4% 29.8% 33.1% 65.9% 67.7% 65.9% 68.4% 68.1% 68.7% 69.9% 75.6% 69.5% 75.7% 70.6% 70.2% 66.9% 46.2% 44.4% 43.4% 44.1% 50.8% 49.7% 46.3% 47.3% 60.2% 30% 26.75% 70% 73.25% Age distribution < 14 14-15 16-17 > 17 Unknown 9.5% 4.9% 2.0% 4.7% 4.6% 5.9% 4.6% 4.6% 5.3% 3.5% 4.4% 4.6% 38.1% 30.0% 22.9% 27.9% 25.6% 24.9% 25.8% 29.8% 30.1% 26.9% 26.5% 28.4% 39.8% 46.4% 43.4% 46.9% 46.6% 50.4% 52.4% 47.5% 46.4% 49% 53.6% 42.9% 12.6% 18.7% 20.5% 16.5% 18.5% 15.9% 17.2% 18.1% 18.2% 20.6% 15.6% 24.1% 11.2% 4.0% 4.7% 2.9% 0% 0% 0% 0% 0% Main substance involved Cannabis Heroin XTC/ Cocaine Legal drugs Polydrug Other None Unknown 83.1% 72.3% 71.5% 73.3% 67.7% 3.5% 4.5% 5.6% 3.7% 2.5% 1.3% 2.2% 0.4% 1.6% 1.1% 2.6% 3.0% 2.4% 3.1% 5.1% d.m. 1.9% 3.2% 3.7% 5.4% 1.3% 3.3% 2.0% 2.5% 2.5% 8.2% 10.6% 10.4% 10.2% 9.6% 0.0% 2.2% 3.7% 2.5% 6.1% Source:IMPULS(Solidarité-Jeunesasbl).2015 132 208 69.4% 72.8% 74.2% 73.8% 76.8% 81.4% 78.7% 1.7% 1.6% 1.1% 0.3% 0.8% 0.0% 0.0% 0.6% 0.9% 0.8% 1.0% 0.4% 0.2% 1.3% 7.8% 6.2% 5.4% 8.2% 9.9% 4.4% 4.8% 4.5% 5.8% 5.1% 5.3% 3.6% 0.0% 4.6% 2.5% 1.7% 1.1% 1.2% 0.6% 1.8% 0.8% 8.7% 6.1% 9.7% 7.3% 7.2% 5.5% 4.6% 4.8% 4.9% 2.6% 2.9% 0.7% 6.7% 5.2% INTERVENTIONS IN THE CRIMINAL JUSTICE SYSTEM The Grand Duchy of Luxembourg counts two state prisons at the national level; the CPL situated in the vicinityofLuxembourgCityandtheCPGimplementedintheEastofthecountry. The CPG, may be considered as an alternative to a strict penitentiary regime as it is defined as a semiopenprisonestablishedinafairlyruralsetting.Duringdaytime,inmatesfollowaprofessionalactivityor participateinoneofthecentre’sworkshops(agriculture,animalbreeding,kitchen,horticulture,woodwork, locksmith’sandduties).Afterworktheyreturntotheirindividualcellsforthenight.Everyblockhasitsown livingroom,kitchen,bathroomandlaundryallowinginmatestoliveinmoreorlessautonomy. 2015 Alternatives to prison Partofinmatesparticipatesinthe‘DEFI’programme(seebelowunder‘Reintegrationofdrugusersafter releasefromprison’)workingoutsideforaminimumloan(RMG–GuaranteedMinimumIncome).Otherslive underasemi-libertyregime(theyliveatCPGbuthaveanindividualandexternalworkcontract). The‘injonctionthérapeutique’isanotheralternativetoprison(onlypossibleincaseofoffencesforpersonal possessionoruseofillicitsubstances):theoffenderisproposedtoundergotreatmentinsteadofaprison sentence.Inothercases,communityservices(‘TIG:travauxd’intérêtsgénéraux’)mayalsobeanalternative (dependingonthegravityoftheoffenceandthesentence).Thesentencemaybesuspendedifthe‘prévenu’ agreestoundergotreatment(‘sursisprobatoire’).Thissaid,thesetwoalternativesareapplicableincaseof drugpossessionoruseonly(notforcasesofproduction,dealingortraffickingofillicitsubstances),asinthe Grand-DuchyofLuxembourgadrugaddictisnotconsideredacriminalbutapersoninneedofpsycho-social andmedicalhelp. AfurtheralternativetoprisonavailableinLuxembourgistheelectronictag.InNovember2006,theMinister ofJusticepresentedtheintroductionoftheelectronictagasanalternativetoincarceration. Inanexperimentalphase,thissystemwasexclusivelymeantforprisoners: - whosesentencewaslessthanoneyear - whodidnotrepresentadanger - whoaresociallyintegratedandresidinginLuxembourg - whowereworkingorundergoingtraining DRUG USE AND PROBLEM DRUG USE IN PRISONS Thestudy‘PrevalenceofviralhepatitisA,BandCandHIVinproblematicdrugusersofillicitlyacquired drugs’(Origer&Removille,2007),alsoaddresseddruguseanddrug-relatedharminprisonsettings.Referredtothetotalstudysample(N:246),56.1%ofrespondentswhohavehadprisonexperienceduringthe pasttenyearsreportedillicitdruguseinprison;30.5%reportedintravenousdruguse.26.7%oflifetime IDUsinmatesreportedneedlesharinginprisonwhichissensiblylowerthantherateobservedin1998by Schlink(1999).Amongallsettings(inpatient,outpatienttreatment,lowthreshold,etc.)prevalenceratesof HIV,HBVandHCVwerehighestinpersonsrecruitedinprisonsettings. 133 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition RESPONSES TO DRUG-RELATED HEALTH ISSUES IN PRISONS Table 9.7: Number of general admissions and the number of admissions according to drug-related convictions (DELIT ‘STUP’) in national prisons from 1989 to 2014. YEAR 1989 1990 1992 1994 New entries (Total) New “STUP” entries 163 244 157 288 1996 1998 2000 2002 2004 2006 2008 2010 2012 2013 2014 685 796 767 794 1.078 1.043 990 927 950 818 904 292 42.6% 161 21% 247 21% 101 12.7% 92 8.5% 243 332 23.3% 33.5% 232 306 226 223 25% 32.21% 27.63% 24.67% Source:CPL,CPG.2015 Drug treatment in prison Followingthelawof27July1997concerningthemodificationofthepenitentiaryorganisation73,apilot projectnamed‘GlobalDrugCareProgrammeinPrison’(2000-2005–TOXproject)wassetupbyagroupof expertsassignedbytheMinistryofJusticein1999.Theconceptwasdesignedtoimplement,amongother objectivesprimarypreventionmeasuresinregardtodrugconsumptionandinfectiousdiseases.Theoverall aimoftheprojectwastointegratedrugdependantinmatesintoamedico-psycho-socialdrugcarenetwork in order to reduce recidivism, risks and criminality after release from prison. The implementation of the projecthadtobeadaptedtothetwodifferentprisonsettings.JointfinancingbytheMinistryofJustice,the NationalFundagainstdrugtraffickingandtheEU(regardingevaluation)wasensured. TheTOXprogramme(previouslyTOXproject)takescareofthedrugdependantinmatesinthetwostate prisonsofSchrassig(CPL)andGivenich(CPG).Thisserviceisrunbyamultidisciplinarystaff.ThebasicprinciplesoftheTOXprogrammeintheCPGarethevoluntaryparticipation,thecooperation,thetransparency, thequalityofservice,thedeterminationofrealisableobjectivesandtheempowermentofparticipants.Additionally,theprogrammeTOXalsopreparesinmatestoenterasecondtreatmentoptionavailableinprison: a“drug-free”programmecalled“Charly”.Theprogrammeprovidesa“drug-free”zone,whereinmatescan servetheirsentence,orpartofit,undercertainconditions.Stayingdrugfreeandacceptingtoparticipatein psycho-socialinterventionsarepartoftheadmissionscriteria. Aspecialprogrammetargetingexclusivelywomenexistsandbecomesoperationalwhenaminimumnumber ofwomenenrol.Otherwise,individualoffersareavailableforthefemalepopulation. Detoxification treatment is either provided in-house under the responsibility of the prison medical unit,orbyexternaldetoxificationunitsofgeneralhospitalsaccordingtostrictrulesandprocedures.CPL hassignedaconventionwithamajorgeneralhospitalsituatedinLuxembourgCityensuringout-of-prison medicalcareifrequired. Psychosocial and therapeutic careisprovidedbyboth,in-housestaffmembersandspecialisedexternal agentsfromaccrediteddrugagencies.Anexampleofgoodpracticeinthisrespectistheinclusionofclearly 73 Thelawof27July1997concerningthemodificationofthepenitentiaryorganisationregulatesthecreationofspecialisedmedical unitsfordrugaddictsandpsychiatricpatientswithinprison. 134 Substitution treatmentisalsoprovidedinprisonbutnotbytheservicesmentionedabove.Thenursery andMDsareinchargeofmethadoneprescriptionwithinprison.Moredetailedfiguresonthistypeoftreatmentcanbefoundinrespectivesections.Threescenariosmayoccur: 2015 timeoncontentdefinedserviceprovidingofexternalspecialiseddrugagenciescontractuallyforeseenby stateconventions(intheframeworkoftheglobaldrugcareprogramme).Thismechanismalsoappliesto external agents in the field of HIV and other infectious diseases. One should also stress the role of the CentralProbationService(SCAS),whichmotivatesinmatestoundergotreatmentandenablescontactswith externaltherapeuticagencies.Althoughthepsychosocialcarestrategyissimilarinbothnationalprisons,the CPGcurrentlydisposesofamorestructuredinterventionprogramme. - mostfrequentlyencounteredsituationappliestonewprisonerswhounderwentsubstitutiontreatment priortotheircurrentincarceration.Medicalprisonstaffinquirestheaccuracyoftheinformation providedbyinvolvedinmatesbycontactingtheprescribingGPorthenationalsubstitutionprogramme. Incaseofconfirmation,substitutiontreatmentiscontinuedandmaybefollowedbymaintenance, dosereductionordetoxificationtreatment, - increasinglysubstitutiontreatmentisinitiatedwithinprison.Italsoincludesinmateswhohavestarted opiatesuseinprison, - opiateusingoralreadysubstitutedprisonersmayintroduceanadmissiondemandtothenational substitutionprogramme6weeksbeforerelease.Continuityofcareandre-socialisationmeasuresare ensuredbytheinterventionofsocialworkersfromexternalfieldagencies(substitution,HIV,hepatitis, etc.). Themainsubstitutionopiatesprescribedinprisonaremethadone(MEPHENON®),andtoalesserextend buprenorphine(SUBUTEX®)andcodeine.Prescriptionofbenzodiazepinesiswidespread. Official figures show that 18% of adult inmates who entered CPL in 2014 received drug substitution treatment,representingatotalof209persons. Table 9.8: Number of prisoners receiving opioid substitution treatment (2014) YEAR 2014 Methadone 154 Subutex ® 16(SUBUTEX+METHADONE)/55(SUBUTEXonly) Total (persons) 209 Source:ComitédeSurveillanceSIDA:Activityreport2015 The average dose of distributed methadone was 21 mg per day (minimal dose 1mg and maximal dose 100mg).Theaverageperiodoftreatmentwas140days. Ofclientsintreatmentunitsinprison,96.6%(96%)aremaleversus3.4%(4%)offemales.Themeanage oftreatmentdemandersis33.47(33yearsand3months),whereastheaveragemaleageis33.61(33Y6M) andthemeanageofthefemaleclientsisconsistentlylower(2014:29Y6M,2013:33Y10M,2012:29Y6M, 2011:29Y).Respectively34%(42%)ofclientsintreatmentarenativesversus66%(58%)ofnon-natives. The population of non-natives consistsfor thevast majorityofPortuguesenationals,followedbyFrench citizens. 135 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Regardingtheeducationalleveloftheclientsintreatment,88%(73%)havecompletedprimaryschool,12% (22%)havecompletedsecondaryschool.39%(38%)ofclientsintreatmentunitsinprisonexperiencedone ormoreoverdoses.Asfarasthesharingofusedsyringesisconcerned,48%(33%)reportedthattheynever sharedsyringesduringtheirlifetime(95%duringthelastmonth,2013:85%). Prevention and reduction of drug-related harm In2014,theactivitiesofthepreviouslyreferredtoTOX-programmeinprisonwerecentredonthreepillars: •psychosocial prevention: psychosocial careofdrug-addictedinmates,inordertopreparetheirfuture afterreleasefromprisonandtoreducerisksofrelapseandrecidivism–intensiveprogrammewithout drugstopreparepost-releaseambulatorytherapyand/orindividualpreparationforrelease. • prevention of the STDs: thishealthserviceisproposedinindividualandcollectivesettings. • coordination of interventions: the drug-addicted platform was created in order to coordinate interventionsofinvolvedprofessionals. TheTOXprogrammeintheCPGhasestablishedpsycho-educationalactivities.Thegrouphasfocusedon twoaxes: • Health development and Specific psycho-educational practice forthedrug-addictedinmates withinacollectivepavilionwithoutdrugs(specificentourageofatleast4monthswithanoptional prolongation). • follow-upofthedrugfreesectiontogetherwiththe“ProgramCharly”startedinMay2007,aspreparation formultidisciplinaryandintensivetherapy. As far as the CPL is concerned, in 2012, 107 demanders were provided with an individual psychosocial follow-up(901counsellingsessions).333clientshavebenefitedfrom33healthpreventiongroupsin2012. For 2012, the CPG reports a total of 122 psychosocial prevention and 78 HIV and hepatitis prevention groupswereheld.305clientswereprovidedwithanindividualpsychosocialfollow-upand1,427individual counsellingsessionswereheld.Atotalof25clientsparticipatedinthe“ProgrammeCharly”. In 2007, the external evaluation report74 of the TOX project has been published and recommended the continuationoftheaction. TheprogrammeiscurrentlypartoftheRELISroutinedatareportingnetworkandfirstdataontreatment demandbecameavailablein2010. PREVENTION, TREATMENT AND CARE OF INFECTIOUS DISEASES Newinmatesareseenbymedicalstaffintheframeworkoftheadmissionprocedureofbothnationalprisons. AHIVscreeningtestissuggestedduringthemedicalcounselling.Iftheinmateaccepts,asimultaneous screeningofotherinfectiousdiseaseslikesyphilisandhepatitisA,BandCisproposed. 74 TREPOS, J.-Y. (2007) Evaluation du projet global de prise en charge des personnes toxicodépendantes en milieu pénitentiaire au Grand-DuchédeLuxembourg,UniversitéPaul-Verlaine,Metz. 136 A structured syringes distribution programme has officially been launched in 2005 in the framework of theglobaldrugcareprogrammeinprison.Inordertoenrol,inmateshavetosendawrittenrequesttothe prison’sMD.Aftercounselling,theinmateishandedakitcontaining2syringeswhichmaybeexchangedat thenursery.Astheconsumptionandpossessionofdrugsisillegal,thoseinmatesinpossessionwithasyringe initskit,areexemptedfromsanctionsfordetentionofinjectionparaphernalia.In2014,46kits(31in2013) havebeendistributedand2,101(1,726)syringesexchanged.Theprogrammeisundermedicalsecrecyandis operationalalthoughaseriesofchangesarecurrentlybeingdiscussedtoincreasethecoverageandimpact oftheprogramme. 2015 In 2014, approximately 808 (692) HIV tests have been carried out. 18 (8 in 2013) tests were positive (16 men and 2 women vs. 6 men and 2 women in 2013), 8 (3 in 2013) co-infections (HIV/HCV) were diagnosed(allwereNONIDUs).Topreventfurthercontamination,vaccinationagainsthepatitisBandAis recommendedtothosewhopresentanegativeserology. Ascorbicacid,filters,sterilephysiologicalwater,antisepticwipesandsmallplastersareavailableatthetwo nurseries.Condomsarealsoavailableatdifferentdiscretespotsoftheprison(atthetwonurseries,TOXprogrammeandatthepsychiatricward). Inordertomeetspecificneedsintermsofinfectiousdiseasesinprisonsettings,thecreationofaspecialised transmittablediseasecounsellingoffer(COMATEP)involvingprisonadministrationandCHLhasbecome operationalin2011. Prevention of overdose-risk upon prison release Overdoseincidentsfollowingprisonreleaseisadocumentedrealitythathasalsobeenaddressedbynational research.Forinstance,theOriger&Delluccistudyin2002recommendedthefollowingmeasurestoprevent overdoseriskfollowinganin-depthlongitudinalanalysisofdrug-relateddeathnationwide: - openingofsupervisedinjectionroomsaccordingtothenationaldrugsactionplan(1) medicalcontrolledheroindistributionprogramme(foreseenbythenationaldrugsactionplan)(2) firstaidtrainingcoursesprovidedtousersandtheirrelativesandpartners(3) genderandethnicspecificinterventions(4) provisionofmorphinereceptorantagoniststousersandselectedpersons(5) creationof‘transitioncentres’forexorcurrentPDUleavinginstitutionalsettings(6) development of reintegration programmes for prisoners in the framework of the recent ‘Global care programmefordrugaddictsinprison’(7) Besides,thelawof27April2001introducedanimportantmodificationofthebasicdruglawwithregardto overdoseprevention.Art.10-1ofthereferredlawexemptsdruguserswhocallforassistanceincaseanother userisinneedofmedicalhelp,fromprisonsentences.Thischangeissupposedtoreducedrug-relateddeaths occurringinconsumergroups.AnewflyeraddressingmeasurestobeundertakenbywitnessesofadrugrelatedoverdoseandthegenuinelegalsituationwaselaboratedandwasbroadlydistributedamongPDU invarioussettingsin2009. Forpersons(withdrugcareers)leavingprison,aseriesofmeasuressuchasinformationandpeereducation, banningmultipleprescriptionsofsubstitutiondrugs,consideringinteractionofsubstitutiontreatmentand concomitant/persistentstreetdruguseandensuringthrough-careafterprisonreleaseneedtobefurther developed. 137 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 REINTEGRATION OF DRUG USERS AFTER RELEASE FROM PRISON The CPL runs a proper psychosocial and educational department (SPSE). Jointly with the SCAS and the prisonguards’association,ithassetupaprojectcalled‘DEFI’(Challenge)thataimsatthedevelopment of therapeutic means, training facilities, socio-professional reinsertion measures and indebtedness management,duringprisonjourneyandaftertheprisonreleasephase. Thefurtherdevelopmentofsynergieswithexternaldrugcareagenciesaimingatacomprehensiveconcept ofthroughcareintermsofpsychosocialmeasures,substitutiontreatmentoreconomicalstart-uphelpare someofthecornerstonesofnationalafter-prisonreintegrationstrategies. 138 INTRODUCTION Drugmarketsareofchangingnature.Theyrelyonfactorssuchassupplymechanisms,ontheeconomic situationofthecountrytheydevelopinandontheefficiencyoflawenforcementstrategies.Availabilityand supplyindicatorsshouldbeinterpretedwithcautionastheyrelyontheinterplayofallthesefactors.Law enforcementauthorities,theNationalLaboratoryofHealthandspecialsurveyshaveprovideddataforthe presentchapter. 2015 10. DRUG MARKETS Overall,thenationaldrugmarkethasbecomeofamoreaggressivenatureintermsofsellingtechniques (e.g.dealersapproachpotentialclientsandnotvice-versa,thedealersinsistonselling).Newdistribution networkshavedevelopedinrecentyearsandoperateinanobviouslyprofessionalwayandbydoingso, havesignificantlyincreaseddrugavailabilityandinparticularthesupplyofcocaineandcannabis.Dealers increasinglytendtoactivelyapproachconfirmedorpotentialclients.Morerecentlyethnicgroupsjointo improvetheirdrugdistributionstrategieswhereaspreviouslynoneofthesecriminalgroupsactivelysearched contactwithothergroups.Moreoverithasbeennotedthattraffickerstendtodelocalizetheirsellingpoints tolocationsorsettingslessvisibletopoliceasforinstanceprivateflatsorbars. Inthelastyears,organisedcrimegroupsfromWesternAfricancountrieshavebeendevelopinglarge-scale cocainetraffickingactivitiesthroughoutEuropeincludinginLuxembourg.Thesegroupsaremostlyformed ofcellularstructures.Thekeytotheireffectivenessistheirabilitytooperateindependentlywhiledrawing onanextensivenetworkofpersonalcontacts.TheirnumberhasbeensteadilyincreasinginLuxembourgand Policehaveobservedastronginclinationtoviolence. Inregardtoherointrafficking,nopredominantprofileofnationalityhasbeenreported.Alargenumberof drugtraffickerscomefromNorthAfricabytransitingthroughBelgium.Numeroustraffickershavechanged fromherointococaineandcurrentlyarealsoinvolvedincannabistraffic. Concerningpurityandpricesofcannabis,heroinandcocaine,averagevalueshavebeenremainingstable duringthelast5years. Intermsofseizedquantities,importantvariationsareobservedforheroinsince2000.Asfarascocaineis concerned,increased quantitieshavebeenreportedin2012.Thenumberofseizuresalsohasbeenshowing greatvariationsduringthesameperiod,especiallyforcannabis. Theperceivedillicitdrugavailabilityingeneralpopulationishighandfollowsaweakincreasingtrend. AVAILABILITY AND SUPPLY Perceived availability of drugs In addition to availability indicators from law enforcement sources, perceived availability of the general public provides further insight in the current situation. Both, the 2004 Flash Eurobarometer 158 survey “YoungpeopleandDrugs”andthe2002Eurobarometer57.2surveyinformaboutthelevelandtheevolution ofillicitdrugsavailabilityintheG.D.ofLuxembourg. 139 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Table 10.1: Ease of acquisition of drugs in Luxembourg (2002/2004) QUESTION a: Is it easy to get illicit drugs? Near where I live In or near my school/ college At parties In pubs/clubs 2002 2004 2002 2004 2002 2004 2002 2004 Luxembourg 62.2 66% 60.5 63% 74.7 74% 73.2 70% EU 61.9 63% 54.9 57% 76.0 79% 72.3 76% InMay2008,theDirectorate-GeneralJustice,LibertyandSecurityoftheEuropeanCommissionpublisheda publicopinionpollnamed“Youngpeopleanddrugsamong15-24yearsolds”(N°233)withinthescopeof Eurobarometersurveys.Questionswereincludedontheeaseofaccesstoillicitdrugs,alcoholandtobacco: The following figure presents the results of the question: “How difficult would it be for you to get hold of any of the following substances if you wanted to?” Table 10.1 bis: Ease of acquisition of drugs in Luxembourg (2008) Ease of access to heroin (ifdesired) very difficult fairly difficult fairly easy very easy dk/na Luxembourg 44 33 14 9 2 EU27 42 30 16 7 5 Ease of access to cocaine (ifdesired) LU 37 30 22 9 3 EU27 35 26 22 11 5 Ease of access to ecstasy (ifdesired) LU 34 31 25 9 2 EU27 31 25 26 12 5 Ease of access to cannabis (ifdesired) LU 17 11 30 41 1 EU27 19 15 31 32 4 Ease of access to tobacco (ifdesired) LU EU27 1 1 10 88 2 15 81 Ease of access to alcohol (ifdesired) LU EU27 140 1 1 5 94 2 17 80 Evenifheroinwasthesubstanceconsideredtobemostdifficulttogetholdof,alsococainewasquotedby 67%ofyoungpeoplefromLuxembourgasmoredifficulttoobtainthandidtheEUaverage(61%). EcstasywasconsideredbeingmoredifficulttoobtaininLuxembourg(65%)comparedtotheEUaverage (56%).Only34%ofyoungstersfromLuxembourgconsideredtheaccesstoecstasyaseasy(EUaverage: 38%). Concerningcannabis,lessyoungstersfromLuxembourg(28%)declaredtheaccesstocannabistobedifficult thantheEUaverage(34%).Fouroutoftenyoungsters(41%)founditveryeasytoobtaincannabis(EU average:32%,threeoutoften). 2015 Concerningheroin,youngstersfromLuxembourgconsidereditslightlymoredifficult(77%)toobtainorto haveaccesstoherointhantheEuropeanaverage(72%).SimilartotheEUaverage,only23%ofinterviewees thoughtthatgettingholdofheroinwaseasy. Luxembourg’syoungstersconsideredtheaccesstolicitsubstancesastobaccoandalcoholaseasierthanthe EUaverage.Concerningtobacco,88%ofyoungstersfromLuxembourgfoundtheaccessveryeasycompared totheEUaverage(81%).Alsotheaccesstoalcoholwasreferredtoasveryeasy(LU:86%,EU:80%). InsummaryonemaynotethatamajorityofLuxembourg’syoungstersareoftheopinionthatlicitdrugsare veryeasilyavailableincontrasttoillicitdrugsseenasverydifficulttoobtainwithhowevertheexception ofcannabis. InMay2011,theEurobarometerstudy“Youthattitudesondrugs”(N°330)providedresultssummarisedin table10.1ter.Althoughanswercategoriesareslightlydifferent,resultsclearlyshowthatacquisitionofillicit drugsisperceivedtobemoredifficultin2011ifcomparedto2008. Table 10.1 ter Ease of acquisition of drugs in Luxembourg (2011) 2011 Ease of access to heroin (ifdesired) impossible very difficult fairly difficult fairly easy very easy dk/na Luxembourg 30 35 24 8 2 1 EU27 24 36 22 8 5 5 LU 22 33 32 9 2 2 EU27 19 28 26 14 8 5 LU 21 33 EU27 20 28 Ease of access to cocaine (ifdesired) Ease of access to ecstasy (ifdesired) 31 9 2 4 25 14 8 4 Ease of access to cannabis (ifdesired) LU 12 10 23 27 25 3 EU27 11 13 15 28 29 4 Ease of access to tobacco (ifdesired) LU 2 EU27 2 2 14 82 2 14 81 1 Ease of access to alcohol (ifdesired) LU 3 3 15 79 EU27 1 2 14 82 1 141 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition InJune2014,theEurobarometerstudy“Youngpeopleanddrugs”(N°401)providedresultssummarised intable10.1quarter.Resultsclearlyshowthatacquisitionofillicitdrugsisperceivedtobeeasierin2014 comparedto2011. Table 10.1 quarter: Ease of acquisition of drugs in Luxembourg (2014) 2014 Ease of access to heroin (ifdesired) impossible very difficult fairly difficult fairly easy very easy dk/na Luxembourg 28 34 20 12 2 4 EU27 30 31 24 9 4 2 Ease of access to cocaine (ifdesired) LU 24 29 29 12 4 2 EU27 24 23 26 17 8 2 Ease of access to ecstasy (ifdesired) LU 26 28 28 12 3 3 EU27 24 24 27 16 7 2 LU 10 16 EU27 12 12 Ease of access to cannabis (ifdesired) 15 34 22 3 17 29 29 1 Ease of access to tobacco (ifdesired) LU 1 2 5 16 76 0 EU27 2 2 3 14 79 0 LU 1 2 4 13 80 0 EU27 1 1 2 15 81 0 Ease of access to alcohol (ifdesired) Concerningheroin,youngstersfromLuxembourgconsidereditslightlymoredifficult(62%;65%in2011)to haveaccesstoherointhantheEUaverage(61%;60%in2011).SimilartotheEUaverage,only14%(10% in2011)ofintervieweesthoughtthatgettingholdofheroinwaseasy. Evenifheroinwasthesubstanceconsideredtobemostdifficulttoobtain,alsococainewasconsideredby 53%(55%in2011)ofyoungpeoplefromLuxembourgasmoredifficulttohaveaccesstocomparedtothe EUaverage(47%;stable). EcstasywasconsideredbeingmoredifficulttoobtaininLuxembourg(54%stable)comparedtotheEU average(48%stable).Only15%(11%in2011)ofyoungstersfromLuxembourgconsideredtheaccessto ecstasyaseasy(EUaverage:23%;22%in2011). AccesstocannabiswasperceivedslightlyeasierintheEU(58%;57%in2011)thaninLuxembourg(56%; 52%in2011).Twooutoftenyoungsters(22%;25%in2011)founditveryeasytoobtaincannabis(EU average:29%stable). 142 Origins of drugs Thenationalproductionofillicitdrugsappearstobeirrelevantintermsofquantitiesandquality.In2014, noclandestinedrug-manufacturinglaboratoryhasbeendismantledatthenationallevel.Lawenforcement sources75indicatethatcurrentlythemajorityofillicitdrugsconsumedintheG.D.ofLuxembourgoriginate fromtheNetherlands(cannabisproductionandtransitofotherdrugs),followedbyBelgium(ecstasyand ATSproduction)andMorocco(cannabisproduction).Tillthebeginningofthenineties,mostofthepersons involvedinillicitdrugdistributionwereconsumerswhosuppliedthemselvesintheNetherlandsoracquired limitedextraquantitiesofdrugsinordertosellthemwithinrestrictedlocalnetworks.Sincetheopeningof EUborders,moreorganiseddistributionnetworkstendtodevelopwithinthenationaldrugmarket. 2015 EU’s youngsters considered the access to licit substances such as tobacco and alcohol as easy as Luxembourgishyoungstersdo.Concerningtobacco,76%(82%in2011)ofyoungstersfromLuxembourg founditsaccessveryeasycomparedtotheEUaverage(79%;81%in2011).Alsotheaccesstoalcoholwas referredtoasveryeasy(LU:80%;79in2011,EU:81%;82%in2011). Insummary,onemaynotethatamajorityofLuxembourg’syoungstersareoftheopinionthatlicitdrugs areveryeasilyavailableincontrasttoillicitdrugsseenasverydifficulttoobtainwithhoweverthenotable exceptionofcannabis. Drug trafficking patterns Theexpansionofmorestructureddistributionnetworks byorganisedcriminalassociationshasbeenreported earlier.Theproportionofnon-nativesinvolvedindrugtraffickinghasbeenincreasinguntil2005andhas been decreasing quite sensibly since then, although non-native drug traffickers represent 70% (75% in 2011).Typically,involveddealerscarrysmallquantitiesofdrugshiddenintheirmouthreadytobeswallowed promptlyincaseofpolicecontrols.Initiallydrugsofhighqualityhavebeensoldatlowprices.Progressively however,thequalityanddiversityofsolddrugshavebeendecreasing.Thenationaldrugmarkethasbeen floodedbyahighproportionoflowqualityinjectiondrugs,whichhasinducedmajorchangesinconsume patternsofnationaldrugusers. Distribution networks are highly organised and have managed to significantly increase the supply and availabilityofdrugsatthenationallevel. SEIZURES Intermsofseizedquantities,importantvariationsareobservedforheroinandcocainesince2000.The numberofseizuresalsohasbeenshowinggreatvariationsduringthesameperiod,especiallyforcannabis andlatelyalsoforheroinandcocaine. Quantities and numbers of drug seizures Strikingvariationshavebeenobservedastothequantityofillicitsubstancesseizedsincethebeginningof thenineties.Alongitudinaldataanalysisindicatesageneraldecreasingtendencyofheroin,cocaineand cannabisseizuresuntil200276.Since2002however,oneobservesasignificantincreaseinthequantityof drugseizuresmainlyconcerningheroinandherbalcannabis.However,thistrendwasnotobservedin2009 and2010forheroin.Cocaineseizures(quantity)arehighlyvariablesincethebeginningofthenineties. 75 NonpublishedinformationfromtheSpecialisedDrugUnitoftheJudicialPolice 76 Non–transitdrugsdestinedtothenationalmarket 143 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Notwithstanding the quantities of cannabis and cocaine seized, the number of seizures has grown discontinuously since 1990. This suggests that more seizures of smaller quantities have been reported. Since2008,thenumberofcannabisandcocaineseizureshasclearlyincreased,whilethenumberofheroin seizuresdiscontinuouslydecreased.Markedly,thenumberofcannabisseizureshasrisenfrom167to1,093 between1994and2014.Thetotalnumberofpersonsinvolvedintraffichasfollowedaconstantupward trenduntil2002andshowedadecreasingtrendlineuntil2013followedbyamarkedincreasein2014 (2014:2,792;2013:2,066;2012:1,782;2011:2210;2010;2,530;2009:1,963persons). Crack (cocaine-base) seizures have not been reported to date by national authorities. The first national seizuresofecstasy type substances(MDMA,MDA,etc.)wererecordedin1994.Afteryearsofrather modestXTCtypepillseizures,2009datarevealedconsistentlyhigheramountsofseizures.In2011and2012 however,theMDMAseizuresshowedagainadecrease.In2013,seizuresofXTCtypepillswereverylow, whereasanincreasewasobservedin2014. Fig. 10.1 Total quantites of national yearly seizures: heroin, cocaine, ecstasy type (1996 - 2014) 24000 16000 8000 0 Cannabis (gr./10) Heroin (gr.) 1996 1998 2000 2002 2004 2006 2008 2010 2011 2012 2013 2014 3087 693 955 252 2369 6700 2882 6197 1258 3084 1905 13921 2934 3592 11358 2957 6255 9298 7673 5297 23897 2648 3810 6732 Cocaine (gr.) 12891 5995 10757 2486 4481 3825 5519 3257 24435 2013 847 4695 MDMA (pills) 5545 145 318 1139 2232 555 107 291 91 137 13 247 Source:SpecialisedDrugDepartmentoftheJudicialPolice2015 144 Fig. 10.2 Total number of national yearly seizures: cannabis, heroin, cocaine, MDMA (1988 - 2014) 1100 2015 1000 900 800 700 600 500 400 300 200 100 0 Cannabis 1988 1990 1992 1996 1998 2000 2002 2004 2006 2007 2008 2009 2010 2011 2012 2013 2014 109 193 332 281 273 406 616 528 581 643 580 772 947 897 821 874 1093 Heroin 81 133 169 284 189 211 185 187 238 254 234 289 292 244 190 127 150 Cocaine 35 32 65 MDMA (pills) 63 22 51 66 113 89 87 83 96 119 94 122 103 169 26 22 15 26 15 9 7 16 10 2 6 10 4 3 Source:SpecialisedDrugDepartmentoftheJudicialPolice2015 Fig. 10.3 Number of offenders involved in seizures according to type of offence (2000-2014) 3000 2500 2000 1500 1000 500 0 2000 2002 2004 2006 2008 2009 2010 2011 2012 2013 Traffic 143 339 502 239 141 224 483 307 212 91 2014 97 Traffic AND/OR use 1013 2202 1258 1575 1487 1963 2530 2210 1782 1980 2792 Traffic AND use 216 335 228 220 263 201 420 286 183 82 210 Traffic AND/OR heroin use of 354 715 399 591 573 432 465 239 290 26 630 Traffic AND use of heroin 129 162 116 99 112 80 93 130 64 23 66 Source:SpecialisedDrugDepartmentoftheJudicialPolice2015 145 è 15 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition Number of illicit laboratories and other production sites dismantled Thelasttimethedismantlingofasyntheticdrugmanufacturinglaboratorywasreportedbylawenforcement datesbackto2003.Sincethen,nofurtherlaboratoryseizureonthenationalterritorywasreported. Accordingtopolicerecords,singlecannabisgrowingfieldsarefoundonafairlyirregularbasis.Localcultures of cannabis remain rather insignificant in terms of quantity and national production is limited to small indoorcannabiscultivations(mostlyforpersonaluseandnotprimarilymeanttoprocureeconomicprofit). PRICE/PURITY Price of drugs at retail level Average street prices of heroin (brown), cocaine and ecstasy type substances have fallen from 1998 to 2002/2003butbroaderpricerangesaswellashighermaximumpricesforcocaine,heroinandcannabis havebeenobservedsince2004,whichisduetoahighvariabilityofpurity.Typicalstreetretailcannabisis soldfor5-25€ pergram,cocaineaveragepricepergramisaround80€andforheroinaround50€. Table 10.2: Price per unit evolution at the street level (1994-2012) 1994 1998 2000 2002 2004 2005 2006 2007 2008 2009 2010 2011 2012 5-6 5-6 2.5-3 7.4 6.2 7 7.3 7.3 7.3 7.3 8 8 7.5 8-10 5-10 5-16 4-10 7-25 10-35 5-30 5-17 5-25 Cocaine 100-150 120-170 90 50 20-120 20-110 30-100 30-100 74.4 50 82 80 50-90 50-90 Cannabis Hashish Marijuana Heroin (brown) 65-150 90-150 70-100 50-200 50-250 60-80 33-100 20-250 14-166 40-250 21-125 20-100 STA 25-30 n.a. 25 n.a. n.a. 5 5 20 n.a. 20 20-35 15-20 Ecstasy 9-13 10.7 7 10 10 5 5 5-15 n.a. 5-15 5-25 5-25 11-13 n.a. n.a. 10 10 n.a. n.a. 5-15 n.a. 12 15-25 10-20 LSD 11-13 Source: SpecialisedDrugDepartmentoftheJudicialPolice(1994-2012),ABRIGADO(2008-2013) Price:expressedinEUROatstreetlevel. Forcannabis,cocaine&heroin(since2009)andamphetamines,pricepergramisindicated. Forheroinandcocaine,minimumpricesrefertotrafficunits(until2008)Maximumandaveragepricesrefertostreet retailquantities. ForecstasyandLSD,priceperpillorunitareindicated. Purity/potency of illicit drugs Comparedtothesituationin2006,purityofcocainehasbeendecreasing(2006:58.80%/2012:41%), andaremarkabledecreaseinaverageheroinpuritywasobservedinthetwolastyears(2011and2012), butslightlyincreasedin2013(13.9%),andremainedstablein2014(13.5%).Attentionhastobepaid tothestrikingdifferencesinmaximumandminimumpuritiesaswellastoahistoricallyhighmaximum concentration of THC in cannabis samples seized in Luxembourg. In 2012, the maximum concentration ofTHCinherbalcannabiswas29.36%.In2014,howeverthemaximumconcentrationofTHCinherbal cannabiswas55.8%(22.9%in2013)showingasignificantincrease. 146 2015 Attentionhastobepaidtothestrikingdifferencesinmaximumandminimumpuritiesofallsubstances. For instance heroin and cocaine show very high maximum purity rates. These values should however be consideredcarefully,thesamplingmaycontainintermediaryseizures,notreadyforstreetconsumptionand towhichcuttingagentsweresupposedtobeadded.HistoricallyhighmaximumconcentrationofTHCin cannabisresinsamplesseizedinLuxembourghasbeenobservedin2014. Table 10.3 Purity of drugs at street level (1996-2014) 1996 1998 2000 2002 2004 2006 2008 2010 2011 2012 2013 2014 Pur. (%) Pur. (%) Pur. (%) Pur. (%) Pur. (%) Pur. (%) Pur. (%) Pur. (%) Pur. (%) Pur. (%) Pur. (%) AVRG. AVRG. Cannabis (THC) Pur. (%) AVRG. AVRG. AVRG. AVRG. AVRG. AVRG. AVRG. AVRG. AVRG. MIN. MAX. AVRG. 8.03 7.96 6.94 7.36 9.82 11.32 10.99 9.09 8.7 0.05 55.8 11.59 9.75 10.3 11.84 7.30 11.28 9.54 9.10 9.24 8.5 9.8 0.05 6.64 55.8 32.46 11.22 16.98 Hashish Marihuana Cocaine 60-90 60-90 60.25 62.99 62.37 58.80 52.00 46.92 46.74 44.45 41 0.02 100 38.1 Heroin (brown) 15-23 20-25 17.59 9.97 17.07 15.80 16.10 24.02 10.08 9.60 13.9 0.94 58.71 13.52 15.09 9.44 7.1 18.2 10.43 15.58 17.03 23.1 4.38 20.17 11.44 71.11 29.77 6.25 26.44 23.52 23.57 53.14 nd 77.88 nd nd 42.89 nd nd 77.3 / / 24.53 / / 96.09 / / 53.55 / / 0.05 nd 0.01 / / / / STA Ecstasy (MDMA) (MDEA) (MDA) 35.5 6.8 Psylocine 0.41 63 / / 77 Sources: SpecialisedDrugDepartmentoftheJudicialPolice/LaboratoireNationaldeSanté.DivisionToxicologie.2015 Purity:Forcocaine,heroinandamphetamines,purityisexpressedinpercentagesofpureactivesubstanceatthestreet level. Forcannabis,purityreferstopercentageofTHC. In2011,S.SchneiderandF.Meys78publishedapaperonanalysisresultsofillicitcocaineandheroinsamples seizedinLuxembourgfrom2005to2010. Abstract:Weassesseddrugpurity,frequencyofappearanceandconcentrationrangesofadulterantsof471 illicitcocaineand962illicitheroinsamplesseizedinLuxembourgfromJanuary2005toDecember2010.For cocainesamplesthemeanconcentrationwaslowestin2009(43.2%)andhighestin2005(54.7%)butnoclear trendcouldbeobservedduringthelast6years.14differentadulterantshavebeendetectedincocainesamples, fromwhichphenacetinhasbeenthemostabundantintermsoffrequencyofappearanceandconcentration until2009.In2010theveterinaryanthelminthicdruglevamisolehasbecomethemostabundantadulterant 77 Ecstasy:doseinmg/pill 78 S.Schneider,F.Meys,AnalysisofillicitcocaineandheroinsamplesseizedinLuxembourgfrom2005-2010,ForensicSci.Int.(2011), doi:10.1016/j.forsciint.2011.06.027 147 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 detected in cocaine samples, its concentrations however remained low (1.5-4.1%). 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Loi du 19 décembre 2014 relative à la mise en œuvre du paquet d’avenir – première partie (2015): 1) portant création du Fonds souverain intergénérationnel du Luxembourg; 2) modifiant: la loi modifiée du 19 février 1973 concernant la vente de substances médicamenteuses et la lutte contre la toxicomanie, p. 5478.Luxembourg:ServicecentraldelégislationRetrievedfromhttp://www.impotsdirects. public.lu/legislation/legi14/Memorial-A---N_-257-du-24-decembre-2014.pdf Servicecentraldelégislation.(2007).Abaissementdutauxd’alcoolemie.Dépistagegeneraldedroguesetautresmesures visantl’ameliorationdelasecuriteroutiere.Luxembourg. ServiceCentraldelaStatistiqueetdesEtudesEconomiques(2014),Annuaire Statistique du Luxembourg 2013,STATEC, Luxembourg. ServiceCentraldelaStatistiqueetdesEtudesEconomiques(2006),Lesactivitésillégalesliéesàladrogue:estimationde leurimpactéconomiqueauLuxembourg,Statnews n° 35/2006 et Bulletin du Statec n° 2-2006,Luxembourg. Servicedesantéautravailmultisectoriel.(2013).Alcool, drogue, médicaments au travail. La prévention sans modération! RetrievedfromLuxembourg:www.stm.lu STATEC.StatistiquesLuxembourg.Retrievedfromhttp://www.statistiques.public.lu/en/actors/statec/index.html Statec. (2015). Le Luxembourg en chiffres. Retrieved from Luxembourg: http://www.statistiques.public.lu/en/actors/ statec/index.html StopAidsNow/Acces.(2015).ÉpidémiologieSIDA.Retrieved20.04.2015,fromhttp://www.sida.lu Thomé,L.(2012),Prévention des assuétudes et promotion de la santé en milieu scolaire,CePT,Luxembourg. Trépos,J.-Y.(2007),Evaluation du projet global de prise en charge des personnes toxicodépendantes en milieu pénitentiaire au Grand-Duché de Luxembourg,UniversitéPaul-Verlaine,Metz. Trimbosinstituut(2009).Evaluation of the national drug action plan (2005-2009)odLuxembourg,Utrecht. Trimbosinstituut(2014).Evaluation of the governmental strategy and action plan 2010-2014 of Luxembourg regarding the fight against drugs and addictions.Utrecht,TheNetherlands:Trimbos-instituutRetrievedfromhttp://www.trimbos. org/~/media/English%20site/AF1345%20Evaluation%20of%20the%20Governmental%20Strategy%20and%20 Action%20Plan%202010%20-%202014.ashx Unitednationsofficeondrugsandcrime.(2014).WorldDrugReport2014.Vienna:UnitedNationsPublications. WorldHealthOrganisation.(1994).LexiconofalcoholanddrugtermspublishedbytheWorldHealth Organization.Retrieved08.04.2015,fromhttp://www.who.int/substance_abuse/terminology/who_lexicon/en/ WorldHealthOrganisation(2014).Worldhealthstatistics.Geneva,Switzerland:WHO. 157 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 ANNEX I LIST OF GRAPHS Fig. 2.1 Fig. 2.2 Fig. 2.3 Fig. 2.4 Fig. 2.5 Fig. 2.6 Fig. 2.7 Fig. 2.8 Fig. 2.9 Fig. 2.10 Fig. 2.11 Fig. 2.12 Fig. 2.13 Fig. 2.14 Fig. 2.15 Fig. 2.16 Fig. 2.17 Fig. 2.18 Fig. 2.19 Fig. 2.20 Fig. 2.21 Fig. 2.22 Fig. 3.1 Fig. 3.2 Fig. 3.3 Fig. 3.4 Fig. 3.5 Fig. 3.6 Fig. 3.7 Fig. 4.1 Fig. 4.2 158 Lifetimeprevalenceaccordingtoage(Fischer1999).................................................................................. 39 Currentandlifetimeprevalenceofcannabisuseaccordingtoage(Cinemasample) (Fischer2000)........................................................................................................................................................... 40 Currentandlifetimeprevalenceofcannabisuseaccordingtoage(Councildistricts) (Fischer2000)........................................................................................................................................................... 41 Lifetimeprevalenceofdruguseaccordingtoage(Matheis,Prussen1995)....................................... 42 Lifetimeprevalenceofdruguseaccordingtoagegroups(Meisch1998)............................................ 43 Lifetimeandlast12monthsprevalenceofanydrug.Age12-18years(valid%) (HBSC1999-2010).............................................................................................................................................. 44 Lifetimeprevalenceofillicitdruguseaccordingtotypeofdrugs.Totalschoolpopulation aged12-18years(valid%)(HBSC1999-2010).......................................................................................... 44 Lifetimeprevalenceaccordingtoageandtypeofdrugs(valid%)(HBSC2010)............................. 45 Lifetimeprevalenceaccordingtoageandtypeofdrugs(valid%)(HBSC1999)............................. 45 Longitudinallifetimeprevalencedataaccordingtotypeofdrugsinagegroup15-16years. (valid%)..................................................................................................................................................................... 46 Longitudinallifetimeprevalencedataaccordingtotypeofdrugsinagegroup13-14years. (valid%)..................................................................................................................................................................... 46 Last12monthsprevalenceofillicitdruguseaccordingtotypeofdrugs. Totalschoolpopulationaged12-18years(valid%)(HBSC1999-2010).......................................... 47 Last12monthsprevalenceaccordingtoageandtypeofdrugs(valid%)(HBSC2010)............... 47 Last30daysprevalenceaccordingtotypeofdrugs:schoolpopulation-13-20years (Fischer2000)........................................................................................................................................................... 48 Lifetime,last12monthsandlast30daysprevalenceofcannabisuse.Age12-18years (valid%)(HBSC1999-2010)............................................................................................................................ 49 Lifetimeprevalenceofcannabisuseaccordingtogender.Age:15years.(HBSC1999-2010)...... 50 Last12monthsprevalenceofcannabisuseaccordingtogender.Age:15years. (HBSC1999-2010)............................................................................................................................................... 50 Last30daysprevalenceofcannabisuseaccordingtogender.Age:15years. (HBSC2006-2010)............................................................................................................................................... 51 Last30dayscannabisprevalenceaccordingtoage(valid%).(HBSC2010).................................... 51 Useofpsychoactivesubstancesduringthelasttwoweeksbypartygoers(valid%)(2012)......... 54 Useofpsychoactivesubstancesduringthelasttwoweeksbypartygoers(valid%)(2013)......... 54 Useofpsychoactivesubstancesduringthelasttwoweeksbypartygoers(valid%)(2014)......... 55 Potentialsourcesofinformationaboutillicitdrugsanddruguse......................................................... 72 Informationchannelsusedinthepastyeartobeinformedabouttheeffects andrisksofillicitdrugs......................................................................................................................................... 73 Howshouldsociety’sdrugproblemsbetackled?......................................................................................... 74 GeographicResidence............................................................................................................................................ 77 Substancesconsumedduringthelast2weeks............................................................................................. 77 NumberofdrugrelatedquestionscominginthroughtheFroNolines (telephoneandemail)in2014........................................................................................................................... 79 Numberofdispatchedleafletsondrugsandpsychotropicmedicationsin2013.............................. 80 Absoluteprevalenceestimatesofproblemdruguseandinjectingdruguse(1997-2009)........... 82 PDUprevalenceratesaccordingtoselectedsub-groups(1997-2009) per1,000inhabitantsaged15-64years......................................................................................................... 84 Prevalenceestimates(problemuseofHRD)andevolutionofselectedindirectindicators............ 85 ProportionofIDUinnewlyinfectedHIVpatients(1985-2014).............................................................. 102 SynopsisofnationaldatainHIVinfectionratesindrugusingpopulations..................................... 103 PreviouscontactswithpsychiatricservicesofRELISindexeddrugusers(1998-2014).................... 1 05 Reasonsforpsychiatriccaredemands(1996-2014).................................................................................... 106 Evolutionofdrug-relateddeathcasesandmortalityratesper100,000inhabitants aged15to64from1990to2014.................................................................................................................... 107 Genderdistributionofdirectdrug-relateddeathcases(1992-2014).................................................... 108 Meanageofacutedrugoverdosevictims(1992-2014)............................................................................. 109 Non-fataldrugoverdosesinRELISrespondents(2004-2014)................................................................. 121 Lastknownhousingsituationofproblemdrugusers(1995-2014)........................................................ 123 Unemploymentrateinproblemdrugusers(1995-2014) ...................................................................... 124 Primarysourceofincomeofproblemdrugusers(1995-2014) ............................................................ 124 EducationallevelofRELISrespondents(2014)............................................................................................. 125 Totalquantitiesofnationalyearlyseizures:heroin,cocaine,ecstasytype(1988-2014)................ 144 Totalnumberofnationalyearlyseizures:Cannabis,Heroin,Cocaine,MDMA(1988-2014)......... 1 45 Numberofoffendersinvolvedinseizuresaccordingtotypeofoffence(1988-2014)..................... 1 45 2015 Fig. 4.3 Fig. 6.1 Fig. 6.2 Fig. 6.3 Fig. 6.4 Fig. 6.5 Fig. 6.6 Fig. 6.7 Fig. 7.1 Fig. 8.1 Fig. 8.2 Fig. 8.3 Fig. 8.4 Fig. 10.1 Fig. 10.2 Fig. 10.3 LIST OF TABLES Tab. 1.1 Tab. 1.2 Tab. 1.3 ComparativeanalysisofdrugdemandreductioncostsinLuxembourg1999vs.2009/2012.... 35 Overallexpenditureinfiscalyear2009by1stlevelCOFOGfunctions.................................................. 36 ComparativeanalysisofdrugrelatedpublicexpendituresinLuxembourg 1999-2009accordingtovariousindicators(EUR)....................................................................................... 36 Tab. 1.4 AnnualbudgetoftheMinistryofHealthallocatedtodrug-demandreduction(2000-2014)..... 36 Tab. 1.5 AnnualprogressionofthebudgetoftheMinistryofHealthandhumanresourcesallocatedto drug-relatedactivities2004-2014..................................................................................................................... 37 Tab. 2.1 HBSC1999/2006/2010:Trendsanalysisaccordingtoageandtypeofdrug(last12months prevalence)................................................................................................................................................................. 48 Tab. 2.2 HBSC2010:Cannabisprevalenceratesaccordingtoagecategories11-15years............................ 50 Tab. 4.1 Absoluteprevalenceandprevalenceratesaccordingtoselectedsub-groups(1997-2009)......... 83 Tab. 4.2 MaincharacteristicsofPDUindexedbythenationaldrugmonitoringsystem,RELIS.................... 86 Tab. 5.1 Drugrelatedinstitutionalcontacts(Inter-institutionalmultiplecountingincluded) RELIS2015/CNS...................................................................................................................................................... 97 Tab. 5.2 Outpatient,prescriptionofsubstitutiondrugsbythenationalnetworkoflicensedMDs (1999-2014).............................................................................................................................................................. 99 Tab. 5.3 Agedistribution(%)ofpatientssubstitutedbythenationalnetworkoflicensedMDs (2008-2014).............................................................................................................................................................. 99 Tab. 6.1 PrevalenceofhepatitisBsurfaceantigens,antibodiestohepatitisBcoreantigen, hepatitisCvirus,andHIVinPDUandever-injectorsaccordingto nationalrecruitmentsettings............................................................................................................................... 103 Tab. 6.2 SynopsisofnationaldataonHIVinfectionrateindrugusingpopulations...................................... 104 Tab. 6.3 SynopsisofnationaldataonAIDSrateindrugusingpopulations....................................................... 104 Tab. 6.4 SynopsisofnationaldataonHCVinfectionrateindrugusingpopulations...................................... 105 Tab. 6.5 Agedistributionofdirectdrugdeathcasesindexedfrom1992to2014............................................ 109 Tab. 7.1 ClientsstatisticsofABRIGADOcentreservices(2005-2014)................................................................... 115 Tab. 7.2 Nationalneedleexchangeprogramme1996-2014includingspecialisedagencies, vendingmachinesandsupervisedinjectionroom........................................................................................ 118 Tab. 7.3 Needleexchangeprogrammeinprison(2005-2014)................................................................................. 119 159 è Tab. 9.1 Tab. 9.2 Tab. 9.3 Tab. 9.4 Tab. 9.5 Tab. 9.6 Tab. 9.7 Tab. 9.8 Tab. 10.1 Tab. 10.1 bis Tab. 10.1 ter Tab. 10.1 quarter Tab. 10.2 Tab. 10.3 NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Arrestsbytypereportinginstitution(1995-2014)....................................................................... 129 Numberofnationallawenforcementinterventions(1995-2014).......................................... 129 Sociodemographicdataon‘prévenus’(1990-2014).................................................................. 130 Distributionof‘prévenus’accordingtofirstoffenceandunderagestatus(1992-2014)... 131 Distributionoffirstdruglawoffenders(useanduse/traffic)accordingtosubstance involvedadminima(1992-2014)...................................................................................................... 131 ClientscorestatisticsIMPULS(2000-2014)................................................................................... 132 NumberofgeneraladmissionsandDELIT‘STUP’admissionsinnationalprisons (1989-2014).............................................................................................................................................. 134 Numberofprisonersreceivingopioidsubstitutiontreatment(2014).................................... 135 EaseofacquisitionofdrugsinLuxembourg(2002/2004)...................................................... 140 EaseofacquisitionofdrugsinLuxembourg(2008).................................................................... 140 EaseofacquisitionofdrugsinLuxembourg(2011).................................................................... 141 EaseofacquisitionofdrugsinLuxembourg(2014).................................................................... 142 Priceperunitevolutionatthestreetlevel(1994-2014)............................................................ 146 Purityofdrugsatstreetlevel(1994-2014)..................................................................................... 147 LIST OF MAPS Map 5.1 160 GeographicalcoverageofspecialiseddrugagenciesintheGrandDuchyofLuxembourg....... 92 RELEVANT DATA BASES AND INFORMATION SYSTEMS a. RELIS drug monitoring system Relying on a multi-sectorial data network including specialised in- and outpatient treatment centres and low threshold facilities, general hospitals as well as law enforcement agencies and national prisons, the RELIS drug monitoring system, established in 1995 by the NFP in collaboration with the Ministry of Health enables the assessment of new trends in the problem drug users population in general as well as in drug treatment demanders in particular. The NFP has opted for a holistic monitoring of the drug population, which by definition, is heterogeneous and not limited to drug treatment demanders. RELIS data refer to HRC drug users indexed by the national specialised treatment and law enforcement network and, as such, defined as problem drug users. 2015 ANNEX II ThemainobjectivesofRELISarethefollowing: presentcomprehensiveinformationonthedrugphenomenonintheGrandDuchyofLuxembourg estimatethedrugprevalenceatthenationallevel(problemdrugusers) unfoldemergingtrends trackanydrug-relatedactivities,betheyinpolicy,demandreductionorresearchareas assesstheimpactofoffer,demandandriskreductionactivitiesoncurrentdrugconsumebehaviours serveasadatabaseforresearchactivities. TheRELISdatacollectionprocedureisbasedonastandardised extensive data protocol including23coreitemsand over60sub-items.Thestandardprotocol,including95percentofthePompidouprotocol’sitems,hasbeenlastmodified in2000inordertoreachcompatibilitywiththeTDI(TreatmentDemandIndicator)standard.TheRELISstandardprotocol includesaseriesofinternalconsistencyitemsthatallowtoassessqualityandconsistencyofprovideddataandtooperate unreliabledataextraction. Asecondprotocol,namelytheActualisation Protocoliscompletedeachtimeapreviouslyknownproblemdruguseris re-indexedafteraperiodofoneyearfollowingthepreviousindexing.Finally,athirdprotocol(Identification Protocol) includingonlytheidentificationcode,thenameofthecontactedinstitutionandthedateandcontextofadmissionis appliedifapreviouslyknownuserisre-indexedinthecourseoftheyearfollowinghispreviousindexing.Theregistration systemallowsforhighlyupdated,detailedandcomparabledataandforafollow-upofinstitutionalcareersofproblem drugusersbymeansofaroutineandcost-effectivedatacollectionprocedure. Toavoidmultiplecountingandtoallowforafollow-upofdrugusers’careers,RELISisbasedona9-digitnumericalcode obtainedbyindating3corevariables(attributers)namely:gender(i.e.01/02),dateofbirth(i.e.10051967),andcountry ofbirthintoacode-calculatordevelopedbytheNFPincollaborationwiththeCRP-HenriTudor.Thesolutionfoundis timeandcosteffectivebecauseitreliesonasimpleHPcalculatorthatrunsanattributor-to-codetranscriptionprogramme basedonamultiple-stepalgorithm. Eachcontactpersonfromtheparticipantfieldinstitutionsdisposesofsuchacalculatorandproducesthecodebyhim/ herself.Thereliabilityintermsofdataprotectionwasapprovedbynationaldataprotectionauthorities,byGermanpartner regionsoftheMondorfGroupandbytheNationalCommissionforInformaticsandLiberties(CNIL)ofFrance. Oneofthemainbenefitsofthedescribedprocedureisthatnopersonaldatacanbeinferreddirectlyfromtheidentification code.Theindatingandencodingproceduresarecarriedoutattheverylevelofthefieldinstitutions.Thus,NFPisprovided with individualised data (reporting protocols) without any reference to identifying information or attributors on the indexedpersons,whichisundoubtedlyoneofthemajorpreoccupationsoffieldinstitutions. RELISdataprocessingisbasedonORACLE®databasesoftwareandallowsformultiplevariablebreakdownsaswell as separated data analysis for different treatment or law enforcement settings. Separate data can be provided for participationregionsandinstitutions. 161 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 Intermsofdataprovision,RELISfurtherreliesonfollowingnationalregisters: - - - - - Registerofdruglawoffenders-SpecialDrugDepartmentoftheJudicialPolice, NationalMortalityRegister-MinistryofHealth, SpecialOverdoseRegister-SpecialDrugDepartmentoftheJudicialPolice, AIDSandHIVRegister-Laboratoryofretrovirology-LIH. Earlywarningsystemonnewsyntheticdrugs b. Register on drug law offenders (SPJ) Theregisterondruglawoffendersispaper-basedandmaintainedbySPJ.Researchandqueriesondruglawoffendersare performedmanually.SpecialauthorisationhasbeenreachedbytheNFPtoaccessthereferredregisterandtomanually includenon-nominativedataonoffendersintotheRELISdatabase.TheNFPthushasdevelopedastandarddatacollection protocolrelyingonSPSS®baseddataanalysis.ThisprocedureshasenabledtheNFPtodisposeofdetailedanonymous dataonalldruglawoffendersindexedbySPJandtooperatebreakdownsreferringtouseandtrafficoffencesandto substancesinvolvedaccordingtotypesofdruglawoffences. c. General Mortality Register (GMR) TheGMRisrunbytheHealthStatisticsDepartmentoftheDirectorateofHealth.Themainimpedimenttowardsrefined dataprovisionondrug-relateddeathsandtheapplicationoftheEMCDDApromotedDRDstandardhasbeenthe3-digit ICDcodingappliedbyGMRuntil1997.In1998,ICD-10standardwasfirstappliedbyGMR.Currently,drug-relateddeath dataareextractedfromGMRbymeansofaseparateextractionroutine.AnintegratedsoftwarebasedontheDRDICD-10 standardallowstoextractDRDcasesfromtheGMRaccordingtoEMCDDAstandards. d. General Mortality Register (GMR) TheSRisapaper-basedregisteronacutedrug-relateddeathsrunbytheSPJ.Overthepastyears,NFPreliesoncomputerbasedindexingprocedure(SPSS®)ofdrug-relateddeathsbymeansofacomprehensivedataform.NFPismaintaininga standardiseddatabaseonacutedrug-relateddeathsfrom1985to2010.Anonymousdrug-relateddeathdataisencoded attheSPJandtransmittedtotheNFPaccordingapprovedstandards. e. AIDS and HIV register (LIH) OfficialstatisticsfromthenationalRetrovirologyLaboratoryoftheLIHprovidethenumberandproportionofIDUinHIV infectedpatients.Breakdownsbylimitedcoresocio-demographicvariablesareavailable.Provideddatahaspublicstatus. f. Early Warning System on Synthetic Drugs (NFP / SPJ) IntheframeworkoftheJointActiononInformationExchange,RiskAssessmentandControlofNewSyntheticDrugs,the NFPhasdevelopedanation-widecross-sectionaldataexchangenetwork Decisionhasbeenmadetoadoptacentralisedstructurerelyingonanation-wideEWSpartners’network(localcontact persons)aswellascentralisedcoordinationofkeydataproviders’activities.ThenationalcoordinationunitofEWSis implementedwithintheNFP.TheheadofNFPhasbeenappointednationalEWScoordinator. The new mandate of the Inter-ministerial Group on Drugs (November 2000), which represents the top decision level in the field of drug policies, expressively includes the follow-up of the national EWS system. Governmental delegatesrepresentedwithintheInter-ministerialGrouphavedisseminatedinformationonEWSwithintheirrespective administrationandhaveundertakentherequiredstepstowardsaneffectiveinter-ministerialcollaboration. 162 Currently,drugseizuresarestilloneofthemostimportantandthemostreliabledatasourceastosubstanceprofiling anddetectionofnewdrugs.SamplesseizedbyCustomsorPoliceareeitheranalysed(rapidtests)bytheSPJ,orsent, via the Prosecutors office, to the National Laboratory of the Department of Health (LNS) for toxicological profiling. RespectiveresultsarenotsystematicallytransmittedtothedepartmentofHealthortheNFP.However,effectivebilateral co-operationbetweentheNFPandthenational Europol unit(SPJ)allowforrapiddatatransmissionincaseanew trendorsubstancesshouldbedetectedbythelatter.Theactiveinvolvementoflawenforcementagenciesinthenational monitoringsystemhighlyfacilitatestheimplementationofJointAction-relatedactivities. 2015 TheimplementationofEWSreliesonanetworkofinstitutionalkey-informants.Currentlyallspecialiseddrugagencies (low/highthreshold)atthenationallevelareinvolvedinthedataprovidingprocessintermsofroutinedatatransmission on new trends. Recently two new agencies have joined the EWS network, namely a counselling centre for drug users underageandalowthresholdproject.Thefirstdoesproviderelevantdataonnewconsumepatternsandtrendswithin youngsterpopulationandthesecondfocusesonopiateusers.Onehastostressthatthekey-informantsnetworkdoes mainlyprovidedataontrendsindrugusebutnotontoxicologicalcharacteristicsofsubstancessincethereferredagencies donotproposesubstancerelatedservices. AgreementshavebeenmadebetweentheNational Fund Against Drug Trafficking, the NFP andthe National Health Laboratory (LNS) onthefundingofnewtechnicalequipmentallocatedthetoxicologyunitofthelatter.Thisachievement haslargelycontributedtotheimprovementofthequalityoftoxicologicalanalysisprovidedbyLNS. General practitionershaverecentlybeeninvolvedintheEWSintermsofdataprovisiononnewsubstancesandnew consumepatterns.AllGPsandpsychiatristsregisteredintheGrand-DuchyofLuxembourghavereceivedastandardised dataformallowingthemtoproviderelevantinformationtotheNFPincasetheywereconfrontedwithanunknownpsychotropicsubstanceorunusualconsumepatterns.TheNFP,asacounterpart,committedtoprovideGPsandpsychiatrists withinformationonthedetectedtrendsorsubstances,asfarasthereisanyinformationavailable. Drug-related deaths have to be reported by emergency services to the Police and the SPJ. Non-fatal drug-related emergenciesrequiringmedicalinterventionhavenottobeenreportedsystematically.Moreover,emergencyservicesdo notindexdrug-relatedinterventionsseparately,whichmeansthatnomonitoringofthosecasescanbeperformed.The referredsituationisnotlikelytochangeandthus,theinclusionofemergencyservicesintheEWSappearstobeunfeasible atthepresentstage. Nationaldruglegislationdoesnotforeseealegalframeworkfortesting or profiling illicit drugsinnightclubs,public eventsorraveparties.Nosuchactivitieshavebeenplannedorcarriedoutundertheauthorityofpublicadministrations. Takingintoaccountthatthefirstofficialseizureof‘ecstasy’hasonlybeenrecordedin1994,harmreductionandclose monitoringactivitiesinthisparticularfieldwerepreviouslynotviewedasapriority. InOctober1995,anew drug help linewascreated,undertheresponsibilityoftheCePT.Givenitseasyaccessandthe anonymityitguarantees,phonehelplinesoftenrepresentthefirststepwithregardtofurtherorientationortreatment demandproceedingsandassuchareabletoprovidehighqualitydataonrecenttrendsindruguse.ThenationalDrug HelpLinehasbeenincludedintheEWSsysteminthecourseof1999.In2008thedrugphonehelplinehasbeenreplaced byadrughelpon-lineservicerunbyCePT(FroNO). Thedrugissueislargelycoveredbyvariousmedia supports.Press,music,fashionandleisureindustriesareoftenthe mirroroflifestylesandcurrenttrendsinsubstanceuse.Informationcouldbecollectedbyscreeningthemediatargetedat youngpeopleandsubculturalgroups.Radio,television,newspaper,magazines,fanzines,books,comics,announcement ofevents,openingofnewclubs,etc.,aretobeviewedascomplementaryindicatorstowardstheglobalmonitoringofnew drugtrends.SincetheresourcesoftheNFPdonotallowforanoverallmonitoringofmediasupports,decisionhasbeen madetocompile,incollaborationwiththeinformationandpressdepartmentoftheState’sMinistry,amonthlynational andinternationalpressreviewondrugs. 163 è NATIONAL DRUG REPORT “GRAND DUCHY OF LUXEMBOURG” New developments, trends and in-depth information on selected issues Edition 15 g. Documentation Centres (NFP / CePT) TheCentre Logistique de Documentation sur les Drogues et les Toxicomanies (CLDDT)isalogisticdocumentation service run by the NFP since 1995. CLDDT runs the only computer-based national documentation management base specificallyfocusingonlicitandillicitdrugs.TheCLDDTindexesabout2,900documentsmainlyinFrench,Germanand Englishlanguage.UsersofinformationservicesprovidedbytheCLDDTaremainlyresearchers,journalists,policymakers, drugtreatmentandpreventionspecialists,andgeneralpublic.Themajorityofindexeddocumentsarepaper-basedand abstractsareprovided. In addition to its function of documentation base, CLDDT also ensures the conceptualisation and execution of drug documentation dissemination strategies as required by the NFP. Topic-specific mailing lists have been developed and maintainedbyactivecontactmakinganddemandresponse. CLDDTislinkedtotheCentre de Documentation du Centre de Prévention des ToxicomaniesrunbyCePTsince 1996.TheCePTdocumentationcentremainlyfocusesonprimaryprevention,trainingandevaluationinthefieldsoflicit andillicitdrugs.Thecurrentstockapproaches1,000documentsormediasupports.Queriesarehandledmanuallyandno computer-basedconsultationfacilitiesareprovided. ALPHABETIC LIST OF RELEVANT INTERNET ADDRESSES http://www.ceps.lu/ http://www.cept.lu/ http://www.crp-sante.lu/ http://www.ecbap.net/ http://eddra.eu.int/ http://eldd.emcdda.eu.int/ http://www.emcdda.eu.int/ http://www.etat.lu/ http://www.etat.lu/MS/ http://www.gouvernement.lu/ http://www.ilres.com/ http://www.jdh.lu/ http://www.legilux.public.lu/ http://www.msr.lu http://www.police.public.lu/PoliceGrandDucale http://www.relis.lu/ http://www.statec.lu/ http://www.unodc.org/ http://www.who.int/ 164 / National Report on the State of the Drugs Phenomenon 1A-1B, rue Thomas Edison L-1445 STRASSEN LUXEMBOURG Tel : (352) 26 97 07 - 39 / 49 Fax : (352) 26 97 07 19 Grand Duchy of Luxembourg New developments,trends and in-depth information on selected issues L’état du phénomène des drogues et des toxicomanies au Grand-Duché de Luxembourg LIH / Point focal OEDT LUXEMBOURG 2015 Point Focal Luxembourgeois de l’Observatoire Européen des Drogues et des Toxicomanies 2015 National Drug Report Point Focal Luxembourgeois de l’Observatoire Européen des Drogues et des Toxicomanies national drug report edition 2015
