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CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS: REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS Drafted by: Iga Kender-Jeziorska (Youth Organisations for Drug Action) Péter Sárosi (Rights Reporter Foundation) Autumn 2018.

CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS: REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS

Colophon: This report is developed within the framework of the European Civil Society Forum Project, which is financed by the European Commission, DG Home. More information via:

www.civilsocietyforumondrugs.eu Authors: Iga Kender-Jeziorska and Péter Sárosi Support: All members of the Working Group 1 of the European Civil Society Forum on Drugs.

Publication design: István Gábor Takács

2 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

Table of Contents

Introduction

Method and Data

2.1.

Data and respondentsâ€™ characteristics

Assessing the role of the EU Drug Strategy and Action Plan

Access to and quality of examined services

4.1.

Prevention (Action Plan 1.1-5)

4.2.

Online prevention (Action Plan 1.3)

4.3.

Safer nightlife programs (Action Plan 1.1.b; 2.8)

4.4.

Drug treatment (Action Plan 2.6-7)

4.5.

Treating co-morbidities (Action Plan 2.7.c)

4.6.

Recovery/Social rehabilitation (Action Plan 2.7)

4.7.

Needle and syringe programs (8.a)

4.8

Opiate substitution treatment (Action Plan 8.a)

4.9.

Naloxone distribution programs (Action Plan 8.b)

4.10.

Drug checking (Action Plan 8.d)

4.11.

Drug consumption rooms (Action Plan 8.d)

4.12.

Alternatives to coercive sanctions (Action Plan 5.22)

Regional analysis

5.1.

Countriesâ€™ features

5.2.

Regional analysis

Access to services among specific populations

Bridging the Gaps: Recommendations from the Civil Society Forum 48

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 3

Figures Figure 1.

Geographical distribution of the respondents

Figure 2.

Areas of work of the respondents

Figure 3.

The role of the EU drug strategy in policy-making on national level (1-100) 12

Figure 4.

Perceived access to services

Figure 5.

Perceived quality of services

Figure 6.

Perception of access to and quality of services

Figure 7.

Perceived access to prevention

Figure 8.

Perceived quality of prevention

Figure 9.

Perceived access to online prevention

Figure 10.

Perceived quality of online prevention

Figure 11.

Perceived access to safer nightlife programs

Figure 12.

Perceived quality of safer nightlife programs

Figure 13.

Perceived access to treatment

Figure 14.

Perceived quality of treatment

Figure 15.

Perceived access to treatment of co-morbidities

Figure 16.

Perceived quality of treatment of co-morbidities

Figure 17.

Perceived access to recovery

Figure 18.

Perceived access to recovery

Figure 19.

Perceived access to needle and syringe programs

Figure 20.

Perceived quality of needle and syringe programs

Figure 21.

Perceived access to opiate substitution programs

Figure 22.

Perceived quality of opiate substitution programs

Figure 23.

Perceived access to naloxone distribution

Figure 24.

Perceived quality of naloxone distribution

Figure 25.

Perceived access to drug checking

Figure 26.

Perceived quality of drug-checking

Figure 27.

Perceived access to drug consumption rooms

Figure 28.

Perceived quality of drug consumption rooms

Figure 29.

Perceived access to alternatives to coercive sanctions

Figure 30.

Perceived quality of alternatives to coercive sanctions

Figure 31.

Perceived access to services by region

Figure 32.

Perceived quality of services per region

Figure 33.

Perceived accessibility among specific populations

4 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

List of tables

Figure 1.

Geography of NGOs’ work and expertise

Figure 2.

Countries ranking

Figure 3.

European regions

Figure 4.

Countries’ features

Figure 5.

Perceived services accessibility by region

Figure 6.

Perceived services quality by region

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 5

1. INTRODUCTION The involvement of non-state actors on various levels of policy-making has been one

of the important issues of the European Union agenda for some time already. One of the manifestations of the EU efforts to include civil society representation in the work of various EU bodies has been creating Civil Society Fora – spaces where European

non-governmental organisations can work together and sit at the round table with EU representatives.

The Civil Society Forum on Drugs (CSFD) is an expert group of the European Commission. Its members are selected by the Commission for a three-years mandate based on their competences, knowledge and expertise. One of its thematic working groups is concerned with the EU drug strategies and action plans.

EU Drug Strategy is a document “provid[ing] the overarching political framework and

priorities for EU drugs policy identified by Member States and EU institutions” (European

Council, 2012), thus setting the general directions of the field development. It is based on the EU values and principles on the one hand, and international agreements (e.g.

United Nations conventions on psychoactive substances) on the other. The strategy constitutes a “base” to guide Action Plans on Drugs – documents encompassing 4-year periods and enlisting more specific actions and measures to be undertaken.

The current EU Drug Strategy was adopted for the years 2013-20, and its Action Plans

for 2013-16 and 2017-20, respectively. The documents focus on few areas of drug

policy: drug demand reduction, drug supply reduction, coordination, international cooperation, and information, research, monitoring and evaluation. With its vocal

support for solutions that are evidence-based and strongly embedded in human rights and public health approach to the drug problem, they are by all means the most

progressive EU documents of this type so far. However, EU strategy and action plans are documents of recommendation character only, i.e. they are not legally binding.

Therefore, each and every EU member state has a full discretion over its drug policy (unless restricted by ratified international treaties), which means that the degree of

following EU recommendation and reflecting them in domestic policies and laws can vary significantly from country to country.

6 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

For this reason, CSFDâ€™s Working Group on the EU Drug Strategy and Action plan has

been involved in in the evaluation of the EU drug strategy (2013-20) and the previous Action Plan on Drugs (2013-16), as well as the preparation of the new Action Plan (2017-20). The Forum has also decided to contribute to the monitoring and evaluation

of the current Action Plan (2017-20). To do so, we have conducted a research among European NGOs working in the field to assess their perspectives and views on how relevant actions of the document are implemented in their countries.

This report consists of five main parts. First, we will describe the methodology and data

sources of this inquiry. Second, we will discuss the services accessibility and quality in general. Third, we will provide a comparative analysis of the European regions included

in the study. Fourth, we will look more closely at services accessibility and quality in the context of few specific and vulnerable populations: youth, elderly, women, ethnic

minorities/immigrants and inmates. Finally, we will present barriers to the effective

implementation of the EU Action Plan and draw a set of recommendations for various stakeholders.

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 7

2. METHOD AND DATA To conduct this exploratory inquiry, an online questionnaire was prepared by the

working group in March 2018 and widely distributed among NGOs working in broadly understood drug policy field from 2nd April to 24th June 2018 via various channels of

online communication. In addition to the organisations based in EU member states, the call invited also those NGOs that are based in some candidate and associated states (Macedonia, Serbia, Montenegro, Norway, Iceland and Switzerland) of the EU.

The first part of the questionnaire focused on the general assessment of accessibility

and quality of the most important services/possibilities for people who use drugs

included in the EU Drug Strategy and Action Plan on Drugs in respondents’ respective countries. To ensure uniform understanding of services definitions, we referred survey respondents to the “Health and social responses to drug problems: a European guide” published by the European Monitoring Centre on Drugs and Drug Addiction (EMCDDA)

in 2017. Twelve services we asked about cover all relevant fields of demand reduction and harm reduction: 1)

Prevention covers a wide spectrum of interventions aimed at preventing or

delaying substance use and associated problems, ranging from those that target society

as a whole (environmental prevention) to interventions focusing on at risk individuals (indicated prevention). 2)

Online prevention in its substance is identical with 1); what is different is the

form and channels of communication used: here we include online settings, e.g. social media, fora. 3)

Safer nightlife programs are programs aiming to increase the level of safety and

reduce levels of risk related to substance use in broadly understood nightlife (party) settings, e.g. distribution of condoms, distribution of free water, so-called psycare activities. 4)

Treatment includes a range of interventions to treat drug problems in Europe,

including psychosocial and medically assisted interventions and detoxification. Drug treatment services may be provided in a variety of outpatient and inpatient settings:

specialist treatment units, primary healthcare and mental health clinics, low-threshold agencies, hospital-based residential units and specialist residential centres. 5)

Treating co-morbidities refers to any treatment interventions, including

community-based interventions, addressing the co-occurrence in the same individual of a psychoactive substance use disorder and another psychiatric disorder. 6)

Recovery/rehabilitation involves programs where an individual temporarily lives

8 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

in a treatment facility and follows a structured, care-planned programme of medical, therapeutic and other activities. 7)

Needle and syringe exchange programs (NSP) provide sterile injection

equipment, information on safer injection and disposal, assistance to access treatment

services and other health and welfare services. They usually constitute a part of some low-threshold services of broader scope. 8)

Opioid substitution treatment (OST) is a type of service for people dependent

on opioid-type substances (e.g. heroin, morphine) to replace illegal opiates with legal medicines. OST improves the health and social well-being of patients, as well as contributes to the prevention of blood-borne viruses’ infections, crime and overdoses. 9)

Naloxone distribution includes various form and channels of distributing

naloxone, a medicine used to reverse opioid overdoses. Administration of naloxone immediately reverses the effect of a drug, restoring vital functions, e.g. breathing. 10)

Drug checking refers to services where individuals can have their substance

tested professionally, e.g. in the laboratory. Drug-checking services are effective in overdose prevention, they enable people who use drugs making informed decisions, and they significantly contribute to early warning systems and mechanisms: detecting

especially dangerous substances is – as a rule – announced publicly and shared widely via various channels. 11)

Drug consumption rooms (DCR) are services which provide safe, clean spaces

for the administration of a substance. They are supervised by medical personnel (doctors, nurses) which contributes to decreasing the level of risk, e.g. of overdose. 12)

Alternatives to coercive sanctions (ACS) refer to interventions/solutions that

provide alternatives to coercive measures. For example, treatment, rehabilitation,

social integration, aftercare and education can be applied instead of incarceration or administrative sanctions.

The scale included 11 points where “0” indicates no access/very low quality, while “10”

indicates full access/excellent quality. The following levels of our variables (accessibility/ quality) have been distinguished: 0 – no access/quality;

0.1-2.0 – very low access/quality; 2.1-3.9 – low access/quality;

4.0 – 5.9 – moderate access/quality;

6.0-6.9 – moderately high access/quality; 7.0-8.5 – high access/quality;

8.6 – 10.0 – very high access/quality.

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 9

2.1. Data and respondentsâ€™ characteristics

The questionnaire was completed by 169 civil society organisations from 32 European

countries. Among respondents representing individual countries we have identified 32

states: 26 EU member states (all except Malta and Luxembourg), 3 candidate states

(Macedonia, Montenegro, Serbia) and three other European states (Iceland, Norway,

Switzerland). The average response number per state was 5. We received a high number of responses (5 or more) from 15 countries and low (2 or less) from 9 countries (see Figure 1.). This means that the reliability of data collected from some countries

is higher than in some others. Still, the overall data reliability is considered high due to selective sampling: our respondents were professionals and experts working in the field.

Figure 1. Geographical distribution of the respondents Montenegro Macedonia Iceland Denmark Latvia Greece Cyprus Croatia Bulgaria Sweden Poland Norway Netherlands Austria Slovakia Romania Germany Estonia Serbia Lithuania Switzerland UK Portugal Italy Slovenia Ireland Belgium Hungary France Finland Czech Republic Spain

1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4

5 5

7 7 7

8 8 8

15 16

16 18

Table 1. Geography of NGOs' work and expertise Scope

Local/city/regional

National

European

10 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

International

Regarding geographical scope of respondentsâ€™ work, most of the examined NGOs

work on local and national level. 18 respondents defined their focus as European while 21 as international (see Table 1.).

Table 1. Geography of NGOsâ€™ work and expertise

Scope

Local/city/regional

National

European

International

Number

Respondents were asked to indicate the areas where they work and have expertise in

(multiple answers were possible). The expertise of our respondents covers all relevant fields of drug policy (see Figure 2.). The majority of them indicated harm reduction and

drug policy advocacy. Over one-third of our respondents have expertise in academic research and in drug prevention, nearly one-third in recovery/rehabilitation, and more

than every fifth in drug treatment. There are 56 organisations that represent communities of people who use drugs, that is, the population most affected by drug policies. 33 organisations indicated that they also work on issues related to incarceration.

Figure 2. Areas of work of the respondents Harm reduction

130

Drug policy advocacy

Research

Prevention of drug use

Drug users representation

Recovery/rehabilitation

Drug treatment

Prisons

33 0

100

120

140

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 11

3. ASSESSING THE ROLE OF THE EU DRUG STRATEGY AND ACTION PLAN We intended to assess what is the role of the EU Action Plan in policy-making processes and actual policies existing in examined countries. We asked respondents to rate this

role on a 0-100 scale where â€œ0â€? indicates no role at all, national policies are not in line with EU drug policies, while 100 is they play a great role and national policies are fully

in line with EU drug policies. The average rate of impact assessed by respondents

was 49. However, the results show a great diversity across Europe, ranging from 23 in Lithuania to 74 in Croatia. In the Figure 3 below, the countries with low number of responses (less than 3) are indicated by the yellow highlight.

Figure 3. The role of the EU drug strategy in policymaking on domestic (national) level (1-100)

Q2: Lithuania Q2: Denmark Q2: Cyprus Q2: Switzerland Q2: Hungary Q2: Austria Q2: Italy Q2: Poland Q2: Norway Q2: France Q2: Belgium Q2: Sweden Q2: Germany Q2: Serbia Q2: Greece EU average Q2: Iceland Q2: Finland Q2: Montenegro Q2: UK Q2: Slovakia Q2: Romania Q2: Ireland Q2: Spain Q2: Netherlands Q2: Slovenia Q2: Portugal Q2: Estonia Q2: Latvia Q2: Czech Republic Q2: Macedonia Q2: Bulgaria Q2: Croatia

30 33 33 33 33 35 36 38 40 43 43 44 46 48 49 49 50 52 53 54 55 55 55 55 56 58 58

65 68 70 73 74

12 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

100

It is important to note that there is no correlation between high access to/quality of services in a country and the perception on how much the impact the EU drug strategy

and action plan had on national/local drug policies. For example, in case of Switzerland, access to services is relatively high but the impact of EU drug policies is low: services

development is completely independent from the EU recommendations. On the other hand, while national/local level strategic documents can follow the exact wording and structure of EU drug strategy in some countries, it does not mean that these documents are adequately implemented.

This can explain perceiving the EU strategy as having a significant impact on domestic

policies in some Eastern-Central European countries, such as Bulgaria, where the national drug strategy is modelled after the EU drug strategy - yet these policies are not

really implemented. In some other countries, such as Croatia, optimism and enthusiasm about the impact of EU documents can reflect real development of and investments in the drug policy field, driven by the EU accession process.

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 13

4. ACCESS TO AND QUALITY OF EXAMINED SERVICES On the aggregate European level, two types of services were rated by the respondents

as moderately highly accessible (6 or more points): OST (6.12) and treatment (6.03). Moderate accessibility was reported in case of NSP (5.73), prevention (5.13), recovery

(5.10), and treating co-morbidities (4.62). Access to online prevention (3.53), alternatives to coercive sanctions (3.51), safer nightlife programs (3.00), naloxone distribution (2.21)

and drug checking (2.05) were rated as low, and access to drug consumption rooms

(1.21) was perceived as extremely low. Figure 4 below shows the ratings attributed to

access to services: no access (0 points) is indicated by dark brown and full access (10 points) is indicated by dark blue, while other ratings, falling somewhere between

the two extremes, are indicated by lighter shades of these two colours. Grey colour indicates the lack of data (“I don’t know”).

Figure 4. Perceived accessibility of services Alternatives to coercive sanctions Drug-checking programs Naloxone distribution programs Drug consumption rooms Opiate substitution treatment Needle and syringe programs Recovery/rehabilitation Treating comorbidities Treatment Safer nightlife programs Online prevention programs Prevention 0,00%

20,00%

40,00%

60,00%

80,00%

100,00%

120,00%

The results of the evaluation access to various Figureof 5.the Perceived quality of services services(Figure 4 and Figure 6) come without much surprise. Indeed, if we talk about harm reduction measures, OST Alternatives to coercive sanctions

and NSP have quite a long tradition in Europe and are widely accepted as healthDrug-checking programs

oriented responses tackle the drug use, though in some regions they are still more Naloxone distributionto programs Drug than consumption rooms controversial in others. On the other hand, drug checking services and drug

Opiate substitution treatment consumption rooms are relatively novel ideas (if we take into consideration European Needle and syringe programs scale) and are still highly contested (by public opinion and decision-makers alike). Recovery/rehabilitation Treating comorbidities 14 | CIVIL SOCIETY VIEWS ON THETreatment IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

Alternatives to coercive sanctions Drug-checking programs

Naloxone programs Besides, theirdistribution legal status can be dubious in the context where drug possession (and Drug consumption rooms in some cases consumption) is criminalised, which is the majority of the examined

Opiate substitution treatment countries. In sum, none of the services examined in this study are perceived as highly Needle and syringe programs

accessible by NGOs representatives which may suggest that drug policy does not Recovery/rehabilitation

constitute a priority area for the decision-makers in studied countries. Treating comorbidities Treatment

In the assessment the services quality, we again used an 11-point scale. In the Safer nightlifeofprograms Figure 5,Online “0” prevention (dark brown) programsindicates very low quality, while “10” (dark blue) indicates Preventionlighter shades of these two colours indicate ratings falling excellent quality. Similarly, 0,00% between the two scale extremes.

20,00%

40,00%

60,00%

80,00%

100,00%

120,00%

100,00%

120,00%

Figure 5. Perceived quality of services Alternatives to coercive sanctions Drug-checking programs Naloxone distribution programs Drug consumption rooms Opiate substitution treatment Needle and syringe programs Recovery/rehabilitation Treating comorbidities Treatment Safer nightlife programs Online prevention programs Prevention 0,00%

20,00%

40,00%

60,00%

80,00%

None of the examined services was evaluated as having low quality. The quality of

NSPs was evaluated as high (7.10) and all the remaining services were rated as having moderate quality, with two of them being very close to “moderately high” threshold and further five crossing the rate of “5”: OST (5.93), treatment (5.75), drug checking

(5.43), treating comorbidities (5.38), recovery (5.37), safer nightlife programs (5.16), DCR (5.09), prevention (5.01), naloxone distribution (4.97), online prevention (4.82), alternatives to coercive sanctions (4.38).

If we compare how access to and quality of services was perceived by professionals

in Europe, we will see that while in some types of services access and quality are evaluated at similar level (e.g. prevention, treatment, OST), while in case of some other services there is a large gap between perceived accessibility and quality (e.g. safer

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 15

nightlife programs, drug-checking, DCR). Interestingly, instances where the access

to services is significantly higher than their quality are not present in our data. The gaps always indicate higher rating of quality and lower of accessibility. Moreover,

these instances are visible especially in cases of newer and more controversial types of services/responses. This may suggest that over time, given constant learning and

aiming for improvement, the quality of these services will further increase, widening the

gap even more, unless more favourable environment for establishing such responses will be created. We can also conclude that these services are highly professional yet not yet accepted by public opinion/policy makers (low accessibility suggests low political support and financing but on the other hand it may also suggest lack of professionals willing to deliver them).

Figure 6. Perception of access to and quality of services 8 7

7,01

6 5,13 5,01

5 4

4,82

5,16

6,03 5,7

5,38 4,62

5,37 5,1

6,12 5,93

5,73

5,43

4,97

5,09

3,8

4,38 3,51

3,01 2,21

2,05 1,21

Access

AC S

D C R

N al ox on D e ru g ch ec ki ng

O ST

N SP

Pr ev en O tio nl in n e pr ev en tio Sa n fe rn ig ht lif e Tr ea tm en C t om or bi di tie s R ec ov er y

Quality

Figure 7. Perceived access to prevention

4.1. Prevention (Action Plan 1.1-5) 9,0 8,5

8,0

7,3 Drug prevention programs were rated by NGO professionals as the fourth most 7,0

6,8

6,6

6,4 6,3 accessible type of 6,5 intervention in the field of drug policy with an average rate of 5.13. 6,0

5,7 5,5 5,4 rather high (5 or more) in 18 countries, with Croatia, Access to prevention was perceived 5,3 6,0

5,0 5,0 5,0 5,0 5,0 4,9

4,8 5,0 and the Netherlands having high (x â‰Ľ 7) perceived 4,6 4,5 Austria of prevention, 4,4 accessibility 4,3 4,3 4,3

4,0

and 4,0 relatively high (x â‰Ľ 6) results of Germany, Czech Republic, Slovakia, Finland, 3,5 3,2

3 3 Slovenia and Greece. Low accessibility was reported in Bulgaria, Serbia, Denmark and 3,0

Latvia (between 3,5 and 3) and the lowest in Macedonia (2). 2,0

1,0

Au s C tria r th oa er tia G lan er ds m R an ep y Sl ubl ov ic a Fi kia nl Sl an ov d e G nia re N ece or Sw wa ed y e Sp n Po ain la C nd yp Es rus to Fr nia a nt nc en e itz egr er o la nd Li U th K u Be ani lg a Po ium r H tuga un l g Ire ary la nd R Ita om ly a Ic nia el Bu an lg d a Se ria D rb en ia m a La r k ac tv ed ia on ia

0,0

16 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

Access

Quality

Figure 7. Perceived access to prevention 9,0 8,5 8,0

8,0 7,3 6,8

7,0

6,6 6,5 6,4

6,0

6,3

6,0

5,7

5,5 5,4

5,3

5,0

5,0 5,0 5,0 5,0 5,0 4,9

4,8

4,6 4,5

4,4 4,3 4,3

4,3

4,0

3,5

3,2

3,0

3 2

2,0 1,0

Au s C tria e t ro he at rl ia C G ze e a n d ch r m s R an ep y Sl ubl ov ic a Fi kia nl Sl an ov d e G nia re N ece or Sw wa ed y e Sp n Po ain la C nd yp Es rus to M Fr nia on an Sw ten ce itz egr er o la nd Li U th K u Be ani lg a Po ium r H tuga un l g Ire ary la nd R Ita om ly a Ic nia el Bu an lg d a Se ria D rb en ia m a M La r k ac tv ed ia on ia

0,0

The quality of prevention was perceived very high or high (x≥7) in five countries: Croatia,

Switzerland, Austria, Montenegro and Sweden. Relatively high (x≥6) results were reported in seven countries and moderate results (4≤x<6) in ten. Also, ten countries

have low or very low perceived quality of prevention, with Norway, Cyprus and Bulgaria closing the list with ratings below 31.

Figure 8. Perceived quality of prevention 10,0

9,0

7,8

8,0

7,3

7,0 6,0 5,0 4,0 3,0

7,0 7,0 6,8

6,7 6,7 6,7 6,7

6,1 6,0 5,9

5,8

5,3 5,4

4,7

4,1 4,0 4,0 4,0 4,0

3,8 3,7 3,6

3,5

3,0 3,0 3,0

2,0

2,7 2,5 1,0

1,0

Sw Cr itz oat er ia la M Au nd on s te tria n Sw egr ed o en Be U lg K Fi ium G nla e n C Ne t r m d ze h a ch erl ny R and ep s Sl ubl ov ic en Sp ia Fr ain Sl anc ov e ak ia Ire H lan un d g Es ary to Ic nia el an M La d ac tv ed ia Po on rtu ia Po gal la nd I G taly Li ree th ce R uan om ia a Se nia N rbia or w C ay y Bu pru lg s ar ia

0,0

Figure 9. Perceived access to online prevention

The 9 data on quality is not available for Denmark in case of all examined services. 8 7

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 17

If we look at the differences between perceived accessibility and quality of prevention,

we can observe the largest differences in favour of quality in Switzerland (2.8) and Belgium (2.1). Further four counties are characterised by differences larger than 1 and

smaller/equal 2 (Montenegro 2.0, Macedonia 2.0, UK 1.9, Sweden 1.5). In all but one abovementioned countries, we can observe moderate accessibility and high quality. In Macedonia, in turn, very low access and moderate quality were reported. The largest differences and in favour of accessibility we can find in Norway (3.0), Greece (2.5), Cyprus (2.5) and Bulgaria

(2.5), while the differences between 1

and 2 are features of Poland (1.6), Austria (1.2), Slovakia (1.2) and Romania (1.3). Among them, in Norway, Poland, Cyprus and Romania we can see moderate prevention accessibility and rather low

“There is a need for quality control for all interventions, school prevention

programs are often based on outdated methods such as DARE-type policemen led prevention programs or programs run by the Church of Scientology.” - Hungary

quality. In Slovakia and Greece, we have moderately high accessibility and moderate or low quality, respectively. In Austria – despite the difference – both service aspects are

rated as high, while in Bulgaria the access is low and the quality – very low. The smallest differences (x<0.5), i.e. situations where accessibility and quality of prevention are on

the same level are observable in countries with moderately high ratings (Germany: 0.1, Finland: 0.3, Slovenia: 0.3), medium ratings (France: 0.1, Hungary 0.3, Ireland: 0.4)

as well as rather low ones (Serbia: 0.3). Data analysis suggests the most developed

prevention services operate in Croatia, Germany, the Netherlands and Austria (both aspect scores above 6.5) and the least developed in Bulgaria and Serbia (both aspects scores below 4).

4.2. Online prevention (Action Plan 1.3)

The internet and social media are playing increasingly important role in human life. This is also true for various activities and measures of educational character, especially in the context of youth. We therefore put special emphasis on online prevention services as one of the crucial platforms of prevention as highlighted by the EU Action Plan.

Compared to offline forms of prevention, online drug prevention seems to be not really well-developed in most EU member and candidate states.

18 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

7,8

8,0

7,3

7,0

7,0 7,0 6,8

6,7 6,7 6,7 6,7

6,0

6,1 6,0 5,9

5,8

43 percent of informed respondents2 5,0

5,3 5,4

reported equal or higher than 5 access to 4,7 4,1

4,0 4,0 4,0 3,8 3,7 3,6 3,5 online4,0prevention programs, as contrasted with 4,0 over 62 percent in case of “traditional” 3,0 3,0 3,0

prevention. Moreover, the ratio of “I don’t know” answers was quite 2,7 high 3,0 2,5 – almost 2,0 19 percent (as opposed to over 3 percent in “traditional” prevention category). This 1,0

1,0 suggests that online prevention activities are still in development stage. The highest

0,0 perceived accessibility was reported in the Netherlands and Switzerland and the lowest

in Italy, Cyprus, Iceland, Macedonia, and Montenegro. In Bulgaria complete lack of such services was reported3.

Figure 9. Perceived access to online prevention 9 8 7 6 5 4

8 7 6

5,5 5,5

5,2

4,7 4,7 4

4 3,9

3,7

3,4

3 2 1

2,8 2,7

2,6 2,5

2,2

1,6 1,5

1 0

Fr UK a G nce re ec La e N tvia o Sl rwa ov y a Ire kia l H an un d Po gar r y R tug om a an l Se ia D rb en ia m ar k Ita C ly yp ru M Icel s ac an M ed d on o te nia n Bu egr lg o ar ia

et h Sw erla itz nd er s l Es and to Fi nia nl a C nd r C ze Lit oat ch hu ia R an ep ia ub Au lic Sl str ov ia en S ia G pa er in m a Po ny Be lan lg d iu m

Regarding quality, the data includes 27 countries (data from Denmark, Montenegro, the Netherlands and Sweden are missing4. In general, perceived quality is higher than perceived access and was rated on moderate level (4.82) overall. Online prevention

quality was rated 5 or above in sixteen countries, with the highest results of Switzerland, Austria, Germany and Latvia. Relatively low quality was reported in eight countries and extremely low in two (Cyprus and Iceland).

2 The ratio was calculated based only on rating responses – “I don’t know” responses were not taken into consideration, i.e. the percentage of at least moderate rating = the number of responses 5-10 / the number of responses 0-10. This logic applies to all similar calculations in this report. 3 Data on Sweden is missing. 4 Bulgaria is also excluded from the list due to reported “0” access. In such case, quality category is not applicable. Such logic follows throughout the report. Moreover, in the data processing we have excluded answers regarding the quality in case of respondents who reported “0” access. The reason for that is simple: we want to examine the quality of existing services and including “0” ratings of quality from respondents who rated accessibility “0” would distort the picture. REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 19

Figure 10. Perceived quality of online prevention 9 8

7,8 7

6,7 6,6 6,6 6,5

6,2

5,7 5

4,6 3,8 3,7

3,3 3,3

3 2,2

2 1

Sw itz

er l Au and G st er ria m a La ny tv ia Fi UK nl a Sp nd Be a in Sl lgiu ov m e G nia re Sl ec o e H vak u C ng ia ze ch Cr ary R oat e ia Li pub th lic R uan om ia a Fr nia an ce Ita Po ly N lan o d Po rwa rtu y M Est gal ac on ed ia o Se nia r Ire bia l C and yp Ic rus el an d

A look at the differences in ratings between the accessibility and quality of online

Figure 11. Perceived access to safer nightlife programs

prevention services in examined countries reveals very large gaps between the two, 9

although a large difference (x>1) in favour of accessibility can be identified only in 8 7,7 7,3

Estonia 7 (3.0), where the access is rated relatively high and the quality low. Cases where 6,1

quality significantly higher than accessibility include: with moderate 6 was evaluated 5,5 5,3 5,3 4,9

4,6 4,5 5 accessibility and high quality Germany (3.0), UK (3.0), Belgium (2.6) and Austria (2.0); 4 3,9 3,8

4 with low access and moderate or high quality Latvia (4.0), Greece (3.0), Slovakia (3.0), 3,1 3 2,8 2,7

3 2,5 2,5 2,3 Hungary (3.0) and Romania (2.5), and with 2,6 very low 2,2 access and low quality Italy (2.2) 2 2 2 2

and Macedonia (2.0). 1 0

0,7

A et us he tr rl ia Sl and ov s Be eni lg a iu Sw S m itz pai er n C la ze nd ch R Ita ep ly ub La lic t Fr via an ce G U er K m Po an rtu y G ga re l Fi ece n H lan un d ga Se ry r C bia ro a Po tia R lan om d Li an th ia u D an en ia m N ark or Sl wa ov y a C kia yp r M Ire us on la te nd ne Es gro t Bu oni lg a ar M Icel ia ac an ed d Sw oni ed a en

The smallest differences were reported in Czech Republic (0.2), Norway (0.3), and N

Poland (0.3). The data shows that the overall best online prevention services can be found in Switzerland and Finland (both accessibility and quality equal or above 6) and

the least developed in Cyprus, Iceland, Macedonia, and Bulgaria (accessibility below 2, quality below or equal 3)5.

5 There is no data for the quality of online prevention for: Sweden, the Netherlands, Denmark and Montenegro. 20 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

4.3. Safer nightlife Plan 1.1.b; 2.8) Figure 10. programs Perceived(Action quality of online prevention 9

Some pioneer safer nightlife strategies and programs, including mostly peer-driven 8 7,8

7 7 7 interventions, have already 6,7 6,6 6,6 been implemented in Europe in the 1990s. A thematic 7 6,5 6,2

6 paper published by the EMCDDA 6- Responding to drug use and related problems in 5,7 6

5 5 5 5harm reduction and law enforcement recreational settings (2012) - describes prevention, 5

4,6

interventions addressing specific risk factors in the nightlife scene. The Action Plan 3,8 3,7

3,3 3,3 programs. aims to “improve availability and effectiveness” of safer nightlife 3 3 3 3

2,2

2 In our survey, 37 percent of respondents reported the access to nightlife services to 1

be at the1 level of five or above. However, the access is perceived high only in Austria 0

(7.7) and0 the Netherlands (7.3) and relatively high in Slovenia (6.1). On the other hand, er l Au and G st er ria m a La ny tv ia Fi UK nl a Sp nd Be a in Sl lgiu ov m e G nia re Sl ec o e H vak u C ng ia ze ch Cr ary R oat e ia Li pub th lic R uan om ia a Fr nia an ce Ita Po ly N lan o d Po rwa rtu y M Est gal ac on ed ia o Se nia r Ire bia l C and yp Ic rus el an d

there are eleven countries reporting low access (x<4), seven reporting very low access Sw itz

(x≤2), and four countries reporting no access at all (Bulgaria, Iceland, Macedonia, Sweden).

Figure 11. Perceived access to safer nightlife programs 9 8 7,7 7

7,3 6,1

6 5 4 3 2

5,5 5,3 5,3

4,9

4,6 4,5

4 3,9 3,8

3,1 3 2,8 2,7 2,6

2,5 2,5 2,3

2,2 2

2 1

0,7

With the respect to quality, the situation looks much more promising6. We still have

quite a few countries where the quality of nightlife services is perceived very low (x≤1,

Croatia, Cyprus, Ireland, Norway) but on the other hand, there are eleven countries where it was rated from very to moderately high. Interestingly, all countries with low or very low scores on quality (Poland, Lithuania, Cyprus, Croatia, Ireland and Norway,

scores from 0.5 to 3.5) have also low or very low perceived accessibility (from 1.0 to 2.5), which indicates embryonic stage of services development. 6

The data on quality for Montenegro, Estonia and Denmark is missing. REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 21

It may, however, also suggest somewhat problematic data reliability in these specific

cases: it is certainly very challenging to assess the quality of services that are highly scarce. On the other hand, in both examined dimensions among five best rated countries

we can find Austria, The Netherlands, Belgium and Switzerland, which indicates high level of development of safer nightlife services.

Figure 12. Perceived quality of safer nightlife programs 10 9

8,7

8,3

7,7

6,7 6,6 6,6 6,4 6,3

5,6 5,3

4,8 4,7 4,5 4,5 4,3

3,5

0,5

Sw itz N erl et a he nd rla nd Au s st Be ria lg G ium er m an y La t v Sl i ov a en H un ia ga C ry ze ch Ita R ep ly ub lic Sp ai n U Sl ov K ak G ia re ec Fr e an Po ce rtu g Fi al nl an Se d R rbia om an Po ia l Li and th ua ni C a yp u C s ro at Ire ia la N nd or w ay

There are eight countries where nightlife services Figure 13. Perceived accessare to perceived treatment to be of better quality than 12accessibility by 2 or more points. The highest advantage of quality over access

can be observed in Hungary (3.9 – low access and relatively high quality), Switzerland 10 10

8,8 (3.4 – moderate access and high quality), Slovakia (3.3 – very low access and 7,8 7,8

8 7,3 7,3 7,3 7,1 7,1 7 7 moderate quality), Germany (3.2), Latvia (2.5) and Belgium (2.2) – with the three latter 6,6 6,5 6,5 6,4 6,4 6,3

5,5 5,5 5,3 The only differences in favour of 6 reported moderate access and high quality. having 5 5 5 5 4,9 4,5 4,4 4,4

4,1 4 3,8 accessibility occurs in Croatia (1.5) and Norway (1.5). In case of Ireland, in turn, 3,5 there 4

are equally low (1.0) results for both categories. Overall, the best services can be found 2

in Austria, the Netherlands and Slovenia (both aspects rated above 6) and the least C C Sw ro ze itz at ch er ia R lan ep d Sl ubl ov ic e Au nia st ria It Po aly Po lan rtu d ga N et Sp l he a rla in N nds or Be wa y G lgiu er m m G any re e Fr ce an Se ce rb ia Es UK t Sl oni ov a Sw aki ed a Ic en el an M La d a t M ced via on o te nia ne Fi gro nl a C nd yp H ru un s Li ga th ry ua Ire nia D lan en d R ma om r k Bu ani lg a ar ia

0 developed – but reported existing – in Norway, Cyprus, and Ireland (accessibility equal

or lower than 2 but larger than 0 and quality equal or lower than 2).

4.4. Drug treatment (Action Plan 2.6-7)

Figure 14.Perceived quality of drug treatment

In all10but10two (Bulgaria and Romania) examined countries, the access to drug treatment 8,5

7,9 7,5as at least moderate (x≥4). Over a half of our respondents rated the was perceived 8 7,1 7

7 6,6 6,5 6,3 6

6 6 as 6 5,9 5,7 5,7 5,7 5,6 in accessibility to this type of services high (x≥7) their while further 37 5,4 5,4 5,2 5countries, 6 5 4,8 4,5 4,5

4 percent as moderate (6≥x≥4). This translates to eleven countries having high or very 3,5 4

2 high accessibility, six of moderately high, and thirteen countries reporting 2moderate 2

access 0 to treatment. In Bulgaria and Romania respondents evaluated the accessibility ze C c h ro R at ep ia u Be bli Sw lg c itz ium er la n Sp d Es ain G ton er ia m a Se ny rb ia Au UK s Fr tria an N Gr ce et ee he c rla e Sl nd ov s a Ire kia la nd I N taly o Sl rwa ov y Li en th ia ua Fi nia nl Po an rt d H ug M un al on g te ary ne g Po ro R lan om d a C nia yp ru La s Sw tvia e Bu de lg n a I r M cel ia ac an ed d on ia

to treatment as low (x<4). C

22 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

Li t

e R

ze ch

Sw itz N et he

Figure 12. Perceived quality of safer nightlife programs

10 9

8,7

8 12 10

8,3

7,7

Figure 7 7 6,713. Perceived access to treatment 6,6 6,6 6,4 6,3

7 6

510 4 3

5,6 5,3

4,8 4,7 4,5 4,5 4,3

8,8 7,8 7,8

8 2 1

7,3 7,3 7,3 7,1 7,1 7

5,5 5,5 5,3

5 4,9

4,5 4,4 4,4

0,5

4,1 4 3,8 3,5

6 0

6,6 6,5 6,5 6,4 6,4 6,3

3,5

4 2 0

C C Sw ro ze itz at ch er ia R lan ep d Sl ubl ov ic e Au nia st ria It Po aly Po lan rtu d ga N et Sp l he a rla in N nds or Be wa y G lgiu er m m G any re e Fr ce an Se ce rb ia Es UK t Sl oni ov a Sw aki ed a Ic en el an M La d a t M ced via on o te nia ne Fi gro nl a C nd yp H ru un s Li ga th ry ua Ire nia D lan en d R ma om r k Bu ani lg a ar ia

Figure 13. Perceived access to treatment

12 10

8,8

Figure 14.Perceived quality of drug treatment

7,8 With respect to7,8the quality of drug treatment, 24 countries received scores 5 or higher. 8 7,3 7,3 7,3 7,1 7,1 7

6,6

6,5 6,5 6,4 6,4 6,3 High (x≥7) 10 quality of treatment can be observed in (in an ascending order): Germany, 5,5 5,5 6 10

5,3 5

4,9 8,5 4,5 4,4 4,4 Moreover, low Estonia, Spain, 7,9 7,5 Switzerland, Belgium, Czech Republic and Croatia. 4,1 4 8

7,1 7

3,8 3,5

4 6,6 6,5 6,3 perceived quality was reported Bulgaria, Macedonia and Iceland. It is quite 6 only 6 6 in 6 5,9 5,7 5,7 5,7 5,6 5,4 5,4 5,2 5

5 4,8

4,5 4,5 4 clear 2that in case of treatment the differences between countries are much smaller than 3,5 4

2 in case of some other services (e.g. safer nightlife). Indeed, it comes without 2a surprise 0 2

ze C ch Cro Sw Cro R zeat itz at ep chia e ia rl u Be bli Re and Sw lg c pu itz iumSlo bli er ve c la nd A nia us Sp t ri Es ain a I t t o G n P al er ia o y m P la a o n Se ny rtu d ga rNb eiat Sp l he a Au UK rla in s N nd Fr tria orw s an B a e N Gr ceG lgi y et ee e um he c rm rla e a Sl nd Gre ny ov s e a F ce Ire kia ran la S ce nd e rb ia I N taly or U E Sl wa sto K ov yS n Li en lov ia th ia S ak ua w ia Fi nia ed nl I c e Po an ela n rtu d L nd H gM a M un Maal ce tvi on g o d a te arynt on ne en ia g Po ro F egr o R lan inla om d C n d y a C niaHu pru yp s n ru L g La s ithu ary Sw tvia an Ire ia e Bu de De lan lg n nm d a I r R a M cel ia om rk ac an B an ed d ul ia ga on ri a ia

since0treatment is one of the most widely accepted and recognised responses to drug problem globally and has a long tradition in most (if not all) examined countries. C

Figure 14.Perceived quality of drug treatment

12 10 8

10 8,5

7,9 7,5 7,1 7

7 6,6 6,5 6,3 6

6 5,9 5,7 5,7 5,7 5,6 5,4 5,4 5,2 5

5 4,8 4,5 4,5

3,5 2

ze C c h ro R at ep ia u Be bli Sw lg c itz ium er la n Sp d Es ain G ton er ia m a Se ny rb ia Au UK s Fr tria an N Gr ce et ee he c rla e Sl nd ov s a Ire kia la nd I N taly o Sl rwa ov y Li en th ia ua Fi nia nl Po an rt d H ug M un al on g te ary ne g Po ro R lan om d a C nia yp ru La s Sw tvia e Bu de lg n a Ic ria M el ac an ed d on ia

“Treatment, rehabilitation and prevention programs are not covered

by the health insurance, patients have to pay. Only detoxification is free of charge in psychiatric clinics.” - Bulgaria

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 23

Comparing the two aspects, we can see that there are four countries where perceived

access to treatment is significantly better than its quality: Macedonia (3.0), Iceland (3.0) Poland (2.3) and Slovenia (2.1). On the other hand, cases where quality of treatment

was rated higher than accessibility include much smaller differences, with the largest ones in Ireland (1.8), Estonia (1.5), Belgium (1.3) and Lithuania (1.2). Overall, we can identify a group of countries where the treatment services are very well-developed

(both examined aspects rated 7 or above): Croatia, Switzerland, Czech Republic and Spain. The only country where both accessibility and quality of treatment were rated low (below 4) is Bulgaria.

4.5. Treating co-morbidities (Action Plan 2.7.c)

A report published by the EMCDDA in 2015 - Comorbidity of substance use and mental disorders in Europe - points out that “the relevance of the comorbidity of mental disorders

in substance users is related to its high prevalence, its clinical and social severity, its difficult management and its association with poor outcomes for the subjects affected.”

The EU Action Plan on Drugs, in line with earlier civil society recommendations, requests member states “to strengthen the diagnostic process and the treatment of psychiatric

and physical comorbidity involving drug use.” In our survey, fifty-nine percent of

respondents reported the access to treating comorbidities on the level 5 or more, which translates to sixteen countries. The access was rated as exceptionally high in Croatia, and the lowest in Sweden.

Figure 15. Perceived access to treatment of co-morbidities 10 9,5 9 8 7 6 5 4

6,8

6,4

6,1 6

5,7 5,7 5,5 5,5

5,4 5,3 5,3

5 4,8 4,8

4,3

4 3,8 3,7 3,5

3,3

3 2

2,7 2,5 1,3

Sw Cro itz at er ia Po lan rtu d Fr gal an Ic ce el Be an lg d C ze iu m ch I R ta ep ly Sl ubl ov ic en S ia G pa N erm in et he an rla y n Au ds st r La ia N tvia or w Po ay la Fi nd n Li lan th d ua ni a U G K r R eec om e an Se ia Es rbia t Bu oni lg a a Ire ria D lan en d m H ar M ung k a M ced ary on o te nia n Sl egr ov o a C kia yp Sw ru ed s en

Figure 16. Perceived quality of treatment of co-morbidities

10 9,5 9 24 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS 9 7,5

5 4,8 4,8

4,3

4 3,8 3,7

3,5 3,3

2,7 2,5

2 If we talk about the other aspect, three countries (Croatia, Austria and Germany) 1,3 were

rated 1as having high (x≥7) quality of treating comorbidities, while in further ten countries 0

it was perceived as moderately high (x≥6). Low quality (x<4) was reported in Serbia, Bulgaria, Macedonia, Montenegro, Cyprus and Slovakia, and very low quality was reported in Sweden (1.5).

Figure 16. Perceived quality of treatment of co-morbidities

6 5,9 5,9 5,8 5,7

5 4,8 4,8 4,7 4,6

4 3,8

2,5 2,5

1,5

ro a Au tia G str er ia m C ze B an ch elg y R ium ep u Es blic to n N Po ia et la he n rla d nd Sp s a Sw La in t itz vi er a la Fi nd nl a Fr nd an Po c rtu e N ga or l w Ic ay el an d Li Ita th ly ua Ire nia la nd Sl U ov K H eni un a g G ary re R ec om e an Se ia B rb M ulg ia ac ar M ed ia on o te nia ne C gro y Sl pru ov s Sw akia ed en

10 9,5 9 9 7,5 8 6,9 6,6 6,5 6,5 6,3 7 6,1 6 6 5 4 3 2 1 0

In this category, there are no countries where accessibility would be rated significantly

higher (more than 1-point difference) than quality. On the other hand, quality of examined services was rated significantly higher (more than 2-point difference) than access in

five countries: Austria (4.0), Estonia (2.8), Ireland (2.5), Slovakia (2.3) and Germany

(2.2) and between 1 and 2 in eight more. Overall, the best treatment of comorbidities

was reported in Croatia, Switzerland, Portugal, France and Iceland (accessibility of at least 6 and quality of at least 5). Cyprus and Sweden close the list with both services aspects rated below 3.

4.6. Recovery/Social rehabilitation (Action Plan 2.7)

The EU Action Plan on Drugs requests member states to expand the provision of

rehabilitation/reintegration and recovery services. According to our data, recovery services are relatively common in almost all member states, with 54 percent of the

respondents reporting moderately high or high (x≥6) coverage of these services. The mean rating is equal or higher than 5 in seventeen countries, while low or very low accessibility (x<4) is observable in six countries.

“There is a need to step up with the recovery plan and social responsibilities.” - UK

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 25

Figure 17. Perceived access to recovery 10 9

8,4

7,3

6,9 6,7 6,7

3 9

5,7 5,6 5,6 5,5

5,4

5 4,8 4,7

4,5 recovery 4,5 4,5 4,3 Figure 17. Perceived access4,6to 4 4

5 4 10

6,3 6,1

2 8

8,4

2 7,3

1 7

6,9 6,7 6,7

6,3 6,1

5,7 5,6 5,6 5,5

5,4

5 4,8 4,7 4,6 4,5 4,5 4,5

C r ze Lit oat ch hu ia R an ep ia H ubl un ic g Au ary st r Sp ia ai n Ita ly G N erm UK et he an rla y n Po ds l Be an lg d Po ium r Sl tug ov al e Es nia to Fi nia nl a Sw Ice nd itz lan er d l N and or w Se ay r G bia re ec La e Sl tvi ov a a Fr kia D anc en e m Ire ark la n M Cy p d ac ru ed s R on om ia a S M w nia on ed te en n Bu egr lg o ar ia

0 6

4,3

2 Quality of recovery services was rated even higher than the access to them, 1with 62

Figure 18. Perceived quality of recovery

percent of respondents rating it 6 or higher, which translates to thirteen countries. In 10 0

9 further9 twelve countries the quality is perceived as moderate (6>xâ‰Ľ4) and in 6 countries 8,1

as low 8 (x<4). The best quality was reported in Croatia, Czech Republic, Belgium, 7,3 7,2 7

6,8 6,8 6,7 6,6 7 Switzerland and Poland, and6,4the in Latvia, Romania and Iceland. 6,3 poorest 6,3 6 5,8 5,7 5,6 5,5 5,3

4 10 3 9 2 8 1 7

3,5

8,1 7,3 7,2 7 6,8 6,8 6,7 6,6 6,4 6,3 6,3

6 5,8 5,7 5,6 5,5 5,3

2,5 2,3

ze C c h ro R at ep ia u Be bli Sw lg c itz ium er la Po nd Li lan th d ua ni a U Au K st r Sp ia a Fi in nl a Es nd to H ni un a ga ry Ita Ire ly G lan er d m Sl an ov y Sw enia e Sl de ov n a N Gr kia et ee he c rla e n Se ds rb M Fra ia ac nc ed e o N nia or Po wa rtu y C gal y B pr M ul us on ga te ria ne g L a ro R tv om ia a Ic nia el an d

0 6

4,7 Figure 18. Perceived quality of recovery 4 4 4

5 4

4,7

3 2

3,5

2,5 2,3

The biggest differences in ratings of the two aspects in favour of accessibility occur in

Iceland (3.0), Latvia (2.0), Lithuania (1.6) and Portugal (1.6). In turn, quality was rated significantly higher than accessibility Sweden (2.5), Switzerland (2.4), Bulgaria (2.0),

26 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

Ireland (1.8) and Belgium (1.6). The ratings for accessibility and quality are identical

(0-point difference) in Croatia, Austria and Slovenia. In sum, the best perceived services (accessibility larger than 7 and quality larger than 6) are functioning in Croatia, Lithuania

and Czech Republic, while the worst perceived situation (both aspects of 3 or lower) occurs in Romania, Montenegro and Bulgaria.

“Social reintegration has to be made more accessible, which presupposes

a concentrated effort on the State’s part to fight stigma, discrimination and ostracism around drug use and addiction.” - Latvia

4.7. Needle and syringe programs (8.a)

Scaling up availability, coverage and access to needle and syringe programs (NSPs)

is part of the new EU Action Plan on Drugs, including indicators based on the WHO recommendations on the comprehensive package of health services for people who inject drugs (that is, member states are required to reach 200 sterile needles per injecting drug user per year coverage). NSPs are quite common services in Europe:

respondents from seventeen countries reported relatively high or high accessibility

(x≥6), while low rates (less than 4) were reported only from seven countries. No access to NSP was reported from Bulgaria and full access was reported from Croatia.

Figure 19. Perceived access to needle and syringe programs 12 10 8 6 4 2

8,9 8,8

8 7,9

7,5 7,5 7,5

7,1 7

7 6,8

6,5

6 5,9 5,8

5,3

4,7 4,5 4,5 3,5

2,7 2,6

2 1,8

1,5 0

ze c h Cr R oa Sw ep tia itz ubl er ic la Au nd st r M Icel ia ac an ed d on ia Po U rtu K Es ga to l Fr nia an La ce t F M in via on la t N en nd et e he gr rl o Sl and ov s en Sp ia N ain or w ay I Be tal y G lgiu er m m G any re e Po ce la Ire nd R lan om d Sl ani o a D vak en ia m Sw ar k Li ede th n ua n Se ia H rbi un a g C ary yp Bu ru lg s ar ia

REPORT BY Figure 20. Perceived quality ofTHE CIVIL SOCIETY FORUM ON DRUGS | 27

8,9 8,8

8 7,9

7,5 7,5 7,5

7,1 7

7 6,8

6,5 not generalised. For example, there “Indicators need to be highly specific, and 6 5,9 5,8

5,3 5 is arguably good coverage of NSP in Ireland; however, many NSP services do 4,7 4,5 4,5

not 4carry the full range of equipment, meaning that PWID may not always be 3,5 3

2,7

able to access the appropriate equipment for their needs.” - Ireland2,6 2

2 1,8

1,5 0

Quality of services is perceived as very high (x>8.5) in Croatia, Iceland, Czech ze c h Cr R oa Sw ep tia itz ubl er ic la Au nd st r M Icel ia ac an ed d on ia Po U rtu K Es ga to l Fr nia an La ce t F M in via on la t N en nd et e he gr rl o Sl and ov s en Sp ia N ain or w ay I Be tal y G lgiu er m m G any re e Po ce la Ire nd R lan om d Sl ani o a D vak en ia m Sw ar k Li ede th n ua n Se ia H rbi un a g C ary yp Bu ru lg s ar ia

Republic and Switzerland. Further sixteen counties scored 7 or more (high quality) and C

4 countries have reported moderately high quality (7>x≥6). Only in Cyprus the quality is perceived as low.

Figure 20. Perceived quality of needle and syringe programs

12 10 10

9,3

8,8

8,1 8,1 8

7,6 7,5 7,5 7,5 7,3 7,3 7,1 7

7 6,7

6,3 6

5,6 5,5 5,3 5,1

4,5 3

ro ze I ati ch ce a R lan Sw epu d itz bli er c l Be and lg iu Fr m an c M La e ac tv M ed ia on o te nia ne gr o Fi UK nl a Es nd t R on om ia Sl ani o a G vak er ia m Po an rtu y g Sp al a N Au in et s he tri rla a n Po ds la nd Ita N ly or w Ire ay Sl lan ov d Li en th ia ua Sw nia ed Se en H rbi un a g G ary re e C ce yp ru s

Only

four

countries

was

NSP

accessibility rated higher than its quality and the largest difference can be found

in Austria (1.0). It is thus clear that overall,

we have good quality services with insufficient coverage. Interestingly, with an exception of Cyprus, in all countries

reporting low accessibility of NSP (x<4) their quality was rated significantly higher (x>5). This group consists of: Slovakia

(difference of 4.0), Hungary (3.3), Serbia (3.3), Lithuania (3.0), and Sweden (2.8).

“The new EU action plan includes a much stronger focus on harm reduction, but more needs to be done to reflect this change at national level ... harm reduction is in crisis in a number of EU

states including Romania, Bulgaria, Hungary, Greece and Poland, with government funding for harm reduction

in these countries falling far short of what is needed.” - international organisation

28 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

4.8. Opiate substitution treatment (Action Plan 8.a)

Opiate substitution treatment is one of the most common form of treating opioid dependence in Europe. The Action Plan calls member states to scale up access to

these services, in accordance with the WHO recommendation on the comprehensive package of health services for people who inject drugs. According to our data, very

high to moderately high access to OST occurs in nineteen countries (with the highest

perceived accessibility in Croatia, Portugal, Switzerland and the Netherlands), while low accessibility (x<4) was reported only for Romania, Slovakia and Iceland.

Figure 21. Perceived access to opiate substitution programs 12 10

10 8,6

8,2 8

7,7 7,6 7,5 7,5

7,4 7,4 7,3 7,3

6,7

6,4

5,5 5,4

5 4,8 4,7

4,2 4,1 4

3,3 3,3 2

C r P oa Sw or tia tu N itze gal e t rl he an rla d n Fr ds an Be c lg e i Au um Sl str ov ia en ia Ita ly G U er K m N any or w C ay yp G ru s re ec Sp e Fi ain nl an M La d ac tv ed ia o Po nia l Es and to Ire nia la M Bul nd on ga te ria n Sw egr C ed o ze ch S e n R e rb ep ia Li ub th lic u H an un ia D ga e n ry R ma om r k Sl an ov ia a Ic kia el an d

Low quality of OST (x<4) Figure was reported only in quality four countries: Cyprus, Macedonia, 22. Perceived of opiate substitution Montenegro and Iceland and in most of them programs it was actually assessed as very low 12

(ratings 1 or 2). On the other hand, at least moderately high quality (x≥6) was reported 10 10

10 in seventeen countries, with Austria and Croatia perceived as having excellent quality

of OST (10). 8,1 8

8 7,8

7,5 7,3 7,2 7 6,9

6,6 6,6 6,5 6,3 6,2 6

“Civil society needs more state funding,

5,7 5,7 5,6 5,5 5,4

5 4,8 the real needs “Think more 5about 4,7 4

for 4harm reduction too, more frequent

and circumstances of the3,5people. To

and a tighter follow up with financed

strategies, projects and programs.”

calls2 for submission on specific grants 0

- Slovenia

Au s C tria ro a N Bel tia et gi h u Sw erla m itz nd er s la n La d tv ia U S K G pa er in m a Fr ny an ce C ze P Ita ch ort ly R uga ep l ub Po lic Li lan th d u Bu ani lg a a G ri a re e Fi ce nl a H n un d ga Ire ry Sl lan ov d ak Se ia r Es bia R ton om ia Sl ani ov a e N nia or Sw wa ed y e C M yp n ac ru M ed s on o te nia ne Ic gro el an d

projects.” - Austria

2 2 involve the people into the design of

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 29

12 10 8 6

er m N or C y G re S Fi nl M La ac ed Po l Es t Ire l M Bul on g te n Sw e C e ze ch S R e ep Li u th u H un D en R om Sl ov Ic el

C r P o Sw or t N itze e t rl he rla Fr a Be lg Au Sl ov

Figure 22. Perceived quality of opiate substitution programs 10 10 8,1 8 7,8

7,5 7,3 7,2 7 6,9

6,6 6,6 6,5 6,3 6,2 6

5,7 5,7 5,6 5,5 5,4

5 4,8 4,7

3,5 2

2 1

Here, contrary to NSPs, service accessibility was usually rated higher than its quality.

The highest differences in favour of accessibility of OST can be found in Macedonia (4.0), Cyprus (3.5), Montenegro (3.0), Slovenia (2.7), Norway (2.6) and Portugal (2.0) –

quite heterogeneous collection of countries. The highest differences in favour of quality were reported in Austria (2.5), Slovakia (2.2), Czech Republic (1.8), Romania (1.7) and

Hungary (1.6). In sum, the perceived most well-developed OST services are functioning

in Croatia, Switzerland and the Netherlands (accessibility equal or larger than 8, quality

above 7) and the least developed in Iceland (both acpects rated less than or equal 2).

4.9. Naloxone distribution programs (Action Plan 8.b)

According to EMCDDA’s report, an estimated 140.000 lives were lost to drug overdose in the past 20 years. Opioid overdose deaths are preventable with harm reduction

measures, such as the distribution of take-home naloxone kits (an “antidote” to opioid overdose) among peers and their families. The EU Action Plan calls member states to “better prevent drug related deaths according to national circumstances as for example in the case of opiates, by providing access to authorised pharmaceutical dosage forms

of medicinal products containing naloxone specifically certified to treat opioid overdose symptoms by trained laypersons in the absence of medical professionals.” However, our data shows that this type of harm reduction service is extremely rare in Europe.

High access was reported only in UK (7.5) and moderately high in Italy (6.2). Six further countries are perceived as having moderate access to naloxone 6>x≥4.

30 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

As many as seventeen countries report low or very low accessibility and six countries no access at all (Bulgaria, Iceland, Latvia, Montenegro, Poland and Romania)7.

Figure 23. Perceived access to naloxone distribution 8 7,5 7

6,2

5,6 5,5

4,9

4,3 4,2 4 3

2,5 2,5

2,4 Figure 23. Perceived access to naloxone distribution 2 1,7 1,6

1,3

1 0,8 0,7 0,5 0,3

U K Ita l Sp y Es ain to Fr nia an N ce o Sl rwa ov y e C nia yp D ru e M nm s ac a ed r k o C nia ro a G tia re e Ire ce la N Fin nd et la he n rl d Li and th s u Sl ani ov a G ak er ia m Po an rtu y g Se al C ze S rbi c h we a R de Sw epu n itz bli er c l Be and lg H ium un g Bu ar lg y a Ic ria el a M L nd on at te via ne g Po ro R lan om d an ia

2 8 7,5 1 7 6,2 0 5,6 5,5 6 5

4,9

4,3 4,2 4

2,5 2,5 2,4

1,7 1,6 2 In contrary, theFigure quality24. of naloxone distribution is perceived to be significantly Perceived quality1,3ofservices naloxone distribution 1

1 0,8 0,7

1 0,5 0,3 higher in Croatia, 10 in many cases. Very high or high perceived quality (x≥7) can 0be0 found 0 0 0 0 0

9 Germany and Italy and Slovenia and moderately high (x≥6) in UK, France, Spain and 9 8,5

Switzerland. Moderate quality is a feature of ten countries and low or very low quality 8 – six. 7

6,2

5,8

5,5

5 5 5 5 4,8 Figure 24. Perceived quality of naloxone distribution

10 4

9 3

3,5

8,5

3 2

8 2

7 1

7 6

K U

Fr a

ro at er ia m an y Ita ly Sl ov en ia

5,8

5,5

4,8

nc e Sw Spa itz in er la n Ire d la n Es d to n G ia re ec N e or w Po ay rtu ga Sl ov l ak Fi ia nl an C d yp N et r he us rla nd s Se rb L i C ze ithu a ch an i R ep a M ub ac lic ed on Be ia lg iu m H un ga Sw ry ed en

6,2

6 0

3,5

Fr a

nc e Sw Spa itz in er la n Ire d la n Es d to n G ia re ec e N or w Po ay rtu ga Sl ov l ak Fi ia nl an C d yp N et r he us rla nd s Se rb L i C ze ithu a ch an i R ep a M ub ac lic ed on Be ia lg iu m H un ga Sw ry ed en

er m an y Ita ly Sl ov en ia

at ia

The data for Austria is missing. REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 31

“While naloxone is mentioned in the

strategy, we know that currently at least 10% of local authorities are not supplying it to high-risk opioid users in

their areas, and recent work by drug policy organisation Release showed that naloxone provision was inadequate in the majority of England.” - UK

There is only one country where naloxone accessibility is rated higher than its quality:

UK (1.3). On the other hand, the ratings favouring quality and exceeding one point of difference can be found in sixteen

countries, with the largest differences in Germany (extreme 7.5 points), Croatia

(6.5), Switzerland (5.3) and Portugal (4.0).

Overall, we can distinguish a group of countries with relatively well-developed

naloxone services where both aspects exceed „5” rate (UK, Italy, Spain and Estonia) and slightly larger group of countries, where they are in an embryonic phase with

accessibility below 2 but larger than 0 and quality below 4 (Lithuania, Sweden, Czech

Republic, Belgium and Hungary). Moreover, we can see quite a few countries with very low access but moderate or high service quality: the Netherlands, Slovakia, Germany, Portugal, Serbia, and Switzerland.

4.10. Drug checking (Action Plan 8.d)

A number of European countries have implemented drug checking services with

“Destigmatising drug use and lowering

messages to recreational drug users.

related problems is important. Better

interventions can possibly save lives.

implementing

states to exchange information and –

services and drug consumption rooms

the aim of providing targeted preventive

the threshold for seeking help for drug

According

these

and quicker access to treatment,

The Action Plan on Drugs calls member

programmes such as drug checking

where applicable – best practices on pill-

[is needed].” - Finland

the

EMCDDA,

harm

reduction

testing programs. According to our survey

findings, access to drug-testing is very low in Europe, with eight countries reporting zero-access and further twelve very low (x≤2). Only four countries are perceived as having the access of 5 points or higher (Austria, Spain, the Netherlands and Slovenia).

“The government needs to do more harm reduction for MDMA and cannabis, and not only for heavy adult opiate users.” - Norway

32 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

itz

er la nd Au st ria Po N l a et he nd rla nd s Sp a Be in lg iu m Fr an ce Ita Po ly rtu ga C l ze ch U K R ep ub Sl lic ov e R nia om an ia Se rb i Fi a nl an G er d m an G y re ec e Ire la nd C yp ru Sw s ed e C n ro at Bu ia lg ar ia

10 ten (xâ‰Ľ6) 0in Low or very low perceived quality of drug-checking is a feature 9,5 countries. 9,3

of only 9four countries (Cyprus, Sweden, Croatia, Bulgaria) and in eight countries drug9

Au st ri et Sp a he a rl i n Sl and ov s C en ze ia ch R U ep K ub Po lic la Fr nd D anc Sw enm e itz ar er k Be lan lg d i C um yp G ru s re ec e Ita Fi ly nl Po an r d R tug om a a l C nia ro a Ire tia la Se nd Es rbia t Sw oni ed a Bu e n G lgar er ia m H an un y g Ic ary el an L d Li atv t M hua ia ac n M ed ia on o te nia ne N gro or Sl wa ov y ak ia

8 7,5 7,5 checking is perceived as 7,4 having moderate quality.

itz

Figure 25. Perceived access to drug checking

9 8,7

7 6,5

6 5,7

10 5 5

9 4 8,7

7 2

6 1

5 0

10 4

9 3

8 2

7 1

6 0

1 9,5 9,3

Figure 25. Perceived access to drug checking

4,1 3,4 3,3

8 3

3,4 3,3

5 3,2

3,2 3

7 2,7

2,7 2,5 2,5

6,5

2,5 2,5 2

1,8 1,7 1,7

1,5

5,7

1,5

5,4 5,4

1,1

0,8 0,7 0,7

5 Figure 26. Perceived quality 5of drug-checking

4,3

0,5 0,5

0,8 0,7 0,7 1 In contrast to low access, the quality of programs was perceived relatively high or high Figure 26. Perceived quality of drug-checking 0,5 0,5 0

2,5

7,5 7,5 7,4

2,5

1,5

6,3 6,3 6,3 6,3

1,5

4,1

1,1

6,3 6,3 6,3 6,3

5,4 5,4

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 33

Even more extremely than in the case of NSPs, here we have no country perceived

as having higher access to drug-checking than its quality. On the contrary, there are twenty-two countries where quality is perceived to be higher than accessibility, with the

highest differences reported in Switzerland (6.8), Poland (5.7), Belgium (4.9), Portugal (4.6), Italy (4.3) and Serbia (4.2). We can thus again speak about good quality services

of insufficient coverage. Overall, the situation looks the best in Austria, Spain and the

Netherlands (both aspects rated above 5.5) and the worst (including only the countries

with reported accessibility) in Croatia, Sweden and Bulgaria where both aspects were rated 2 or below.

4.11. Drug consumption rooms (Action Plan 8.d)

Supervised drug consumption facilities, where illicit drugs can be used under the supervision of trained staff, have been operating in Europe for the last three decades. According to EMCDDA, these facilities primarily aim to reduce the acute risks of disease

transmission through unhygienic injecting, prevent drug-related overdose deaths and connect high-risk drug users with addiction treatment and other health and social

services. The Action Plan on Drugs calls member states to exchange of information and where applicable best practice on drug consumption rooms. According to our data,

this type of services is the least accessible among all examined services in Europe: any access was reported from fourteen states, but in seven of them it is perceived extremely low (rated less than 2).

Figure 27. Perceived access to drug consumption rooms 8 7 6 5 4

6,7 5

4,2 4 3

2,1

1,5 1,5

0,8 0,8

0,5 0,5

Sw N itze e t rl he an r d G lan er ds m an Sp y D a en in m N ark or w Fr ay an C ce y Sl pru ov s en ia Ire UK la Se nd C ze r ch Cr bia R oat ep ia u Au blic Be stri lg a Bu ium lg Es aria to Fi nia nl G and r H eec un e g Ic ary el an d Ita La ly Li tv M thu ia a a M ced nia on o te nia ne Po gro Po lan r d R tug om a l Sl an ov ia Sw aki ed a en

1,1

Figure quality drug consumption rooms Reported quality was28. highPerceived in Switzerland, theofNetherlands, France and Spain (xâ‰Ľ7) and 10 relatively high in Ireland (xâ‰Ľ6). Moderate quality is a perceived feature of Germany, UK, 9,2 9 8

7,7

7,4

7 34 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS 6 5,7

1,1

0,8 0,8

0,5 0,5

Czech Republic and Serbia, while in four remaining countries the perceived quality of DCR is low (x<4).

Figure 28. Perceived quality of drug consumption rooms 10 9

9,2 7,7

7,4

5,7

4 3

2,7

at ia ro C

ay w or N

Sl ov en ia

yp ru

ze ch

bi a Se r

ep ub lic

K U

er m an y

la nd Ire

Sp ai n

nc e Fr a

ds la n

et he r

itz

er la nd

Perceived access to DCR is higher than perceived quality only in Norway (0.3). On

“We need to introduce needle and

than accessibility in twelve countries, with

open more than the only two drug

the other hand, quality was rated higher

syringe programs for prisoners and

large differences found in France (5.3),

consumption rooms.” - France

Ireland (5.2), UK (3.9), Czech Republic

(3.5) and Spain (3.2). In sum, DCRs are the best-developed in Switzerland, Germany and the Netherlands (both aspects equal or above 5).

4.12. Alternatives to coercive sanctions (Action Plan 5.22)

Action 22 in the EU Action Plan on Drugs (2017-20) requires member states “to provide and apply, where appropriate and in accordance with their legal frameworks, alternatives

to coercive sanctions for drug using offenders.” As part of the implementation of this

action, the European Council adopted its Conclusions on the alternatives to coercive

sanctions (ACS) on 8 March 2018. All member states have at least one ACS and a study produced by RAND identified at least 108 ACS in the EU. Access to ACS is

– according to our data – perceived equal or higher than 5 points in nine countries. The highest access was reported from Portugal, Hungary, Austria and the Netherlands

(x≥6). Extremely low access (x≤2) was reported in six countries, with Montenegro reporting no access at all.

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 35

Figure 29. Perceived access to alternatives to coercive sanctions 8 7 6,8 6,6 6,5 6

5,5

5,1 5

4,5

4,1 4

3,8 3,7

3,5 3,5 3,5

3,1 3

2,5 2,5

2,2

1,5

0,5

Po r H tuga un l g N Au ary et s he tr rla ia nd Sp s ai n Ita C ly r S oa Sw lov tia itz en e ia C ze S rlan c h we d R de ep n G ub er lic m a Se ny N rbia or Be wa lg y Es ium to G nia re e Fr ce D an en ce m Ire ark la Po nd la nd U L K R atv om ia a Fi nia nl a Ic nd Li elan th d u Sl ani ov a ak M Cyp ia ac ru ed s o M Bul nia on ga te ria ne gr o

The quality of ACS is perceived relatively high (xâ‰Ľ6) in five countries: Switzerland,

Spain, Austria, The Figure Netherlands and Poland. Further nine countries are perceived as 30. Perceived access to alternatives

toand coercive sanctions having ACS of moderate quality nine as low, while very low rates were reported 8 from Iceland, Lithuania, Slovakia, Cyprus, Romania and Bulgaria. In nine countries the 6,8

7 6,5 access to 6,6ACS is perceived as higher than its quality, with the highest differences 6

6 in Portugal (1.8),5,5Hungary (1.8) and Romania (1.5). Countries with the largest large 5,1 5

advantage of quality over accessibility include: Poland (3.0), Belgium (2.8), Greece 5 4,5 4,1

(2.5) and UK (2.0). Overall, ACS4 3,8 seem to be the most well-developed in Portugal, 3,7 4 3,5 3,5 3,5

3,1 3 3 3 3 Austria, the Netherlands and Spain (where at least one aspect is equal or higher than 3 2,5 2,5

2,2 2 5 and the other equal or higher than 6). On the other extreme we2 have Cyprus and 2

1,5

Bulgaria where both aspects are rated equal or lower than 2. 1

0,5

Figure 30. Perceived quality of alternatives to coercive sanctions

7 6 5 4 3

6,2 6,1 6

5 4,8 4,8 4,8 4,6

4 3,8 3,7 3,6 3,6 3,5 3,4

2 1

2,4

2 1,8

1,3

1 0

itz

er la n Sp d ai N Au n et s he tri rla a n Po ds la C nd ro Po atia rtu Be ga lg l H ium un C ze Sl gar ch ov y R eni ep a G ubl er ic m an La y Sw tvia ed en U N K or w ay Ita Se ly r Es bia to Fi nia nl a Fr nd an G ce re e Ire ce la Ic nd e Li lan th d ua Sl ni ov a a C kia yp R ru om s a Bu nia lg ar ia

36 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

Above analysis gives some hints regarding the accessibility and quality of various services in different countries. However, to make the picture clearer, we also developed

a ranking of countries with respect to the examined services. We calculated an average

of accessibility and quality for each country in each service category (if data on at least one aspect was not available, the country was not rated at all in given service

category8). Based on overall averages, we ranked countries from 1 to maximum 32.

In case of two countries having identical average, they were assigned the same rank; therefore, in some categories the ranking includes less positions. Countries having reported 0 access to services were ranked 32 regardless of the length of the scale for

other services9. Subsequently, we calculated average of each country ranks across all

categories.

This procedure resulted in following list: Table 2. Countries Ranking

Country

Average rank

Country

Average rank

Switzerland

4,92

Poland

15,67

Croatia

5,67

Norway

15,75

Austria

5,73

Ireland

16,33

Spain

6,42

Serbia

17,17

Netherlands

6,64

Hungary

18,42

8,25

Latvia

18,83

Czech Republic

8,75

Slovakia

18,83

Germany

9,00

Lithuania

19,00

Slovenia

9,00

Cyprus

19,83

France

10,25

Sweden

21,00

Belgium

10,50

Romania

21,58

Italy

12,83

Macedonia

23,18

8 Dania, due to unavailability of data on quality in each examined category, is excluded from the ranking. 9 For example, it is possible that countries with certain service access are ranked 1-20 and countries with no access are all ranked 32 in the same service category.. REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 37

Finland

13,42

Montenegro

23,20

Portugal

13,42

Iceland

23,25

Estonia

14,60

Bulgaria

26,67

Greece

15,25

As we can see, the five countries with overall best-perceives services are Switzerland,

Croatia, Austria, Spain and the Netherlands. On the other extreme we have Sweden, Romania, Macedonia, Montenegro, Iceland and Bulgaria all of which ranked in the third ten on average. However interesting, it should be kept in mind that the results of some countries are less reliable than others due to limited number of responses.

Low number of responses from some countries may also slightly distort the picture. For

that reason, in following chapter we will conduct a regional analysis, comparing the state of drug policy across European regions.

38 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

5. REGIONAL ANALYSIS Not only overall European data and the data for individual countries are interesting, but also regional comparison is worth attention since it may reveal some additional trends

or phenomena. To assign our examined countries into regions we have used Eurovoc

classification with a small modification. We have distinguished a separate group – Western Balkans – from Central-Eastern European countries as defined by Eurovoc.

The reason for such decision is that three countries classified as belonging to CEE region – Serbia, Montenegro and Macedonia – are EU candidate countries and their situation is somewhat different than those who are EU members.

Therefore, our regional classification looks as follows (last row in the table indicates the total number of responses collected from each region10):

Table 3. European regions

Western Europe

Central-Eastern Europe

Western Balkans

Southern Europe

Northern Europe

Austria

Bulgaria

Macedonia

Cyprus

Denmark

Belgium

Croatia

Montenegro

Greece

Estonia

France

Czechia

Serbia

Italy

Finland

Germany

Hungary

Portugal

Iceland

Ireland

Poland

Spain

Latvia

Netherlands

Romania

Lithuania

Switzerland

Slovakia

Norway

Slovenia

Sweden

It is clear that not only we face the disproportions between the number of answers within the regions but also across them.

10 In some cases, there are large disproportions between the number of answers from each country. Thus: in Western Europe disproportions are the lowest, 20% of responses are from France and 52% altogether come from France, UK and Ireland combined; Central-Easter Europe is dominated by Czech Republic (32%) but also responses from Czech Republic, Hungary and Slovenia add up to 68% of the responses in the region; Western Balkans are dominated by Serbia (70% of all responses in the region); Southern Europe is dominated by Spain (47%); Northern Europe is dominated by Finland (41%). REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 39

Still, it is the largest amount of data on the civil society perceptions of EU Drug Action Plan implementation collected until this day. Therefore, our report, though not without

“More interaction is needed between

the current state of drug-related services

The implementation of the EU Action

certain limitations, sheds some light on

the Health Ministry and civil society.

in EU member states and beyond.

Plan should be monitored by both

sectors.” - Netherlands

5.1. Countries’ features

Before we move to the regional comparison, let us present short country characteristics.

The table below contains all examined countries, the services rated as the best and the worst11, as well as the most and least well-developed group of services12 in the

perception of our respondents. We also include the number of services that are not available at all in a country as well as standard deviation of the means of services categories ratings.

Table 4. Countries’ features13

Best service(s)

Austria

OST

Belgium Bulgaria

OST OST Treatment, NSP, OST

Croatia

Best category

Worst category

Number of missing services

Recreational HR

Opioid/IV HR

1.23

Treatment Treatment

Opioid/IV HR Recreational HR

1 5

1.10 1.06

DCR

Treatment

Recreational HR

3.28

Worst service(s) Online prevention Naloxone ACS

Standard deviation

Cyprus

Prevention

Recreational HR

1.18

Czech Republic

Online prevention

NSP

Naloxone

Treatment

Opioid/IV HR

1.18

11 The calculations include mean of both accessibility and quality; the table takes into consideration only services reported as available in a given country. 12 We distinguish between following groups of services: Prevention (prevention and online prevention), treatment (treatment, treatment of comorbidities, recovery), opioid/intravenous harm reduction (NSP, OST, DCR, Naloxone), recreational-settings harm reduction (safer nightlife, drug-checking). 13 Characters “*” indicate missing data regarding the accessibility of certain services. The number of “*” indicated the number of types of services where the data is missing. Therefore, in countries indicated by “*”, the number of inaccessible services can be in reality higher (by maximum of the number of “*”) than the number given in the table. 40 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

Insufficient data

Treatment Prevention Opioid/IV HR Treatment Treatment Treatment

Prevention Recreational HR Recreational HR Recreational HR Recreational HR Opioid/IV HR

1** 1 0 0 1 2

Treatment

Prevention

1.72

Treatment

Recreational HR

1.37

Treatment

Prevention

1.11

Treatment Treatment

Recreational HR Recreational HR

3 2

0.75 1.97

Opioid/IV HR

Prevention

1.68

Prevention Recreational HR Treatment Treatment

Opioid/IV HR Treatment Recreational HR Opioid/IV HR

4** 0* 1 2

2.47 0.60 2.14 1.30

Treatment

Prevention

0.94

Treatment

ACS ACS ACS Drug-checking Drug-checking Naloxone Online prevention Safer nightlife Online prevention ACS ACS Online prevention Recovery Naloxone Safer nightlife Safer nightlife Naloxone, online prevention ACS

Insufficient data 0.71 1.35 0.84 1.16 0.72 1.36

Prevention

Opioid/IV HR

0.53

Serbia

OST

DCR

Treatment

Prevention

0.88

Slovakia Slovenia

Prevention Treatment

Recreational HR Opioid/IV HR

2 0

1.55 0.34

Spain

Treatment

Prevention

0.37

Sweden

Prevention

Recreational HR

2.34

Switzerland UK

NSP OST

ACS DCR Prevention, online prevention Drug-checking, treating comorbidities Naloxone DCR

Opioid/IV HR Opioid/IV HR

Prevention Recreational HR

0 0

0.31 0.59

Insufficient data

Ireland

NSP NSP NSP OST OST Recovery Treating comorbidities OST

Italy

Naloxone

Latvia Lithuania

NSP Recovery

Macedonia

NSP

Montenegro Netherlands Norway Poland

NSP OST Treatment Recovery

Portugal

NSP, OST

Romania

Denmark Estonia 14 Finland France Germany Greece Hungary Iceland

Based on the table above we can see that if we think of groups/categories of services

or so-called “pillars” of drug policy, in the vast majority of examined countries treatment

services are the most developed – this is the case in nineteen out of 32 countries. On the other hand, it seems that harm reduction services are the least developed – they are the worst rated category of services in 22 countries altogether (opioid/IV harm reduction in 8 and recreational setting harm reduction in 14).

14 The data on safer nightlife programs and drug-checking is not available, hence, they were not taken into consideration. REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 41

What is also worth attention, however, are the values of standard deviation (SD). Using

this statistical measure, we can have a look at the dispersion, hence we can see how balanced the policies of our examined countries are. In other words, the smaller the value, the closer were ratings of services categories to the average rating of all categories of services. Therefore, we can see that the most balanced policy is a feature

of Switzerland (SD=0.31), Slovenia (SD=0.34), Spain (SD=0.37) and to a lesser extent

Romania (SD=0.53), UK (SD=0.59) and the Netherlands (SD=0.60). Still, we should remember that in some of these countries this means balanced and effective drug policy (e.g. Switzerland) and sometimes it means balance on quite poor level (e.g. Romania).

On the other hand, we can also identify few countries where pillars (or services

categories) ratings were more scattered: Croatia (SD=3.28), Montenegro (SD=2.47), Sweden (SD=2.34) or Norway (SD=2.14). Given the information included in the table,

we can see what the focus of a country is, i.e. which services dominate, and which are underdeveloped

5.2. Regional analysis What strikes in the first place is the size

of gaps between some regions. Western

Europe has by all means the mostdeveloped services among examined countries: it leads in ten out of twelve service

types. In the remaining two (naloxone

“Barriers are based at local level cities have resources but don’t have knowledge how effectively allocate funding for drug policy.” - Poland

distribution and alternatives to coercive sanctions) it is overtaken by Southern Europe.

Southern Europe has excellent results also in other categories, though sometimes it falls behind Central-Eastern Europe, which is especially visible in case of prevention

and treatment. Northern European countries reach (and very slightly cross) the rating of 5 in only five services types. The most poorly accessibly services, however, are the

feature of Western Balkans which clearly lag behind other examined regions, with the exception of NSP where they place on the 2nd position right after Western Europe.

The table below presents the means of accessibility of each examined service across regions.

42 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

OST

HR Opioid/IV HR

DCR

0.59

Southern Europe

AC S

D C R

ST N al ox D on ru e gch ec ki ng

Pr ev O en nl et in io e n pr ev en Sa tio n fe rn ig ht lif e Tr ea tm C en om t or bi di tie s R ec ov er y Western Europe

N SP

Figure 31. Perceived access to services by region

8 7 6 5 4 3 2 1 0

Recreational HR

Central-Eastern Europe Western Balkans Northern Europe

Table 5. Perceived services accessibility by region

Western Europe

Central-Eastern Europe

Western Balkans

Southern Europe

Northern Europe

Online prevention

4.73

3.45

1.4

2.68

3.79

Safer nightlife

4.81

2.96

1.2

3.46

1.78

Treatment

6.63

6.26

5.47

6.5

5.14

Comorbidities

5.23

4.84

3.27

4.8

4.2

Recovery

5.45

5.41

3.2

5.22

5.06

NSP

6.86

5.03

5.67

5.36

5.55

OST

7.39

5.49

5.27

7.34

5.05

Naloxone

2.67

1.14

1.33

3.86

2.18

Drug-checking

3.56

1.93

0.27

2.94

0.78

DCR

2.84

0.31

0.27

1.14

0.88

ACS

4.26

3.53

1.6

4.38

2.93

AVERAGE

5.02

3.83

2.70

4.39

3.50

Prevention

5.8

5.61

3.4

5.04

4.68

We can see that indeed, Western Europe has overall highest level of services accessibility (though it is not really high in absolute terms, i.e. given that our scale

included values 0-10). Second best access can be found in Southern Europe and

third in CEE. As discussed above, Western Balkans are in significantly worse position,

losing 0.8 point to Northern Europe and with services access almost twice as low as in Western European countries.

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 43

DCR ACS AVERAGE

0.31 3.53 3.83

0.27 1.6 2.70

1.14 4.38 4.39

0.88 2.93 3.50

AC S

D C R

ST N al ox D on ru e gch ec ki ng

N SP

Figure 32. Perceived quality of services per region

Pr ev en nl et in io e n pr ev en Sa tio n fe rn ig ht lif e Tr ea tm C en om t or bi di tie s R ec ov er y

8,00 7,00 6,00 5,00 4,00 3,00 2,00 1,00 0,00

2.84 4.26 5.02

Western Europe

Southern Europe

Central-Eastern Europe Western Balkans Northern Europe

Already the first look at the data on perceived service quality allows for observation that

the variance between regions is not as large as in the case of services accessibility. It is also clear that all the ratings of quality are overall significantly higher than those of accessibility. Here, however, Western Europe leads in all services types, followed

by CEE and Southern Europe (depending on the service). Interestingly enough, in

few services types Northern European countries overtake Southern Europe (i.e. NSP,

prevention, treating comorbidities). Even more interestingly, Western Balkans overtake Northern Europe in five services types: prevention, safer nightlife, drug-checking, DCR and ACS. In prevention and NSP they are also ahead of Southern Europe. The table below presents the means of quality of each examined service across regions.

â€œAfter the Global Fund withdraw from Bulgaria, needle and syringe exchange in the country stopped, the so-called transition [to domestic resources] covered only a few HIV-testing programs.â€? - Bulgaria

44 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

Table 6. Perceived services quality by region Central-Eastern Europe

Western Balkans

Southern Europe

Northern Europe

Online prevention 5.97

5.23

4.14

4.15

Safer nightlife

6.39

4.83

4.5

4.92

3.75

Treatment

6.53

6.09

4.53

5.74

4.89

Comorbidities

6.76

5.49

3.27

4.68

5.09

Recovery

6.15

5.83

5.02

4.79

NSP

7.54

7.49

7.1

5.72

7.21

OST

7.59

6.23

3.13

5.98

4.87

Naloxone

5.5

5.2

2.5

5.4

4.16

Drug-checking

6.79

4.55

5.32

3.15

DCR

6.83

2.67

5.2

2.7

ACS

5.09

4.21

4.5

4.68

3.53

AVERAGE

6.48

5.22

4.18

5.06

4.40

Prevention

Western Europe 6.56

4.78

“We do not only need financial support from the government but also political support.” - Serbia

4.67

3.86

4.49

Again, Western Europe is clearly leading, followed by CEE and Southern Europe

(with very similar results) and further by Northern European countries and Western

Balkans.

Interestingly,

the

difference between services quality perceptions in Western Balkans are this time

only slightly behind Northern Europe and about only one-third worse of those of the Western countries. Here we can also talk about really “high” rates of services as in some categories regions reach the level of 6 or even 7 points on our 0-10 scale. To sum

up, we can thus say that from the regional perspective, the accessibility of examined

services is moderate (Western Europe, Southern Europe) or low (CEE, Northern Europe, Western Balkans), while their quality is perceived as relatively high (Western Europe) or moderate (all other regions).

To add another dimension to our analysis and make it – to the extent possible – comprehensive, in the next chapter we will examine the accessibility of studied services among specific vulnerable populations.

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 45

6. ACCESS TO SERVICES AMONG SPECIFIC POPULATIONS In this chapter we focus on four main types of services, namely, prevention, treatment, harm reduction and recovery/rehabilitation). We focus on these services accessibility among five specific target groups: (i) migrants/ethnic minorities, (ii) prisoners, (iii) ageing people, (iv) young people and (v) women. Similar to previously discussed issues, here we also used an 11-point scale (0-10).

“In general, there is a very poor support

for prisoners in Iceland, there is no

harm reduction in prisons, no OST and no drug treatment. This very much needs to change.” - Iceland

The data shows that the mean access

to services overall is perceived relatively

moderate among all special populations taken together: its mean value equals 4.24.

However, there are significant differences

between examined populations. Migrants/ ethnic minorities have perceived the lowest

access to examined services, with mean access at 3.11. The most accessible service for them is treatment, and the least accessible – recovery. On the other hand, in all but one

service categories women are the ones whose accessibility to services is the highest

with the mean of accessibility equal 5.16. The only service where women’s access is not the highest is prevention: here youth is perceived and having the best possibilities of accessing. Young people are overall in the 2nd position (right after women) Ageing people follow with the mean of perceived access 4.41, and prisoners fall further

behind with the mean equal 3.44. In all examined groups except youth, treatment is the most available service from all services examined (mean 4.83). Overall

accessibility of all other services is quite equal (means between 4.03 and 4.07).

“There is a need for more labelled

funding in both national and EU level on harm reduction, tailored to the needs

of specific vulnerable populations,

including Roma people who live in segregated settlements.” - Hungary

However, it is clear that availability of some types of services is especially problematic

in certain groups. First and foremost, very low level of harm reduction accessibility for prisoners should be of concern, given their environment and the prevalence of risky

behaviours, related to drugs and sex alike. Given that very often prison services are reluctant to accept any harm reduction interventions, special advocacy efforts should be considered to address his problem.

46 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

ACS AVERAGE

5.09 6.48

4.5 4.18

4.68 5.06

3.53 4.40

Figure 33. Perceived accessibility among specific populations

7,0 5,9

6,0 5,0

4.21 5.22

4,8

4,0

5,3 5,3

4,5 4,6 3,4

3,0

5,7

5,3

3,2

4,3 3,5

3,5

3,4 2,8

4,9 4,7

4,4

2,7

2,6

2,0 1,0 0,0

Prevention Women

Harm reduction

Young people

Aeing people

Treatment Prisoners

Recovery

Migrants/ethnic minorities

â€œLanguage is a barrier to prevention and harm reduction services. Also, there is a lack of trust among ethnic minorities. Ageing populations do not tend to

require prevention or harm reduction services. Although if this group require support there is excellent treatment and recovery services available.â€? - Czech Republic

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 47

7. BRIDGING THE GAPS: RECOMMENDATIONS FROM THE CIVIL SOCIETY FORUM Based on the findings of the report and on consultations with European CSOs, the Civil Society Forum on Drugs is making the following recommendations to decision-makers and European institutions to contribute to bridging the gaps between the ambitious goals of the EU Action Plan on Drugs and the reality on the ground.

To the European Commission:

To strengthen the drug coordination system at the EU Commission by providing

To take the leadership in coordinating the implementation and evaluation of the

adequate staff and funding to the Drug Unit and keep its multidisciplinary approach.

current EU Drug Strategy and Action Plan on Drugs and the creation of the new EU Drug Strategy in 2019. 3.

To initiate a dialogue with those member states that, according to this report, do

not provide or provide low access to services required by the EU Action Plan and call them to implement it. 4.

To promote and enhance the European approach to drug policies â€“ in line with

To the EMCDDA:

To involve civil society in a meaningful way in the collection and analysis of

To conduct a comparative study in the European Union about the financial

To promote and support studies, including all member states, on health, social

To monitor and evaluate innovative and experimental policies (at local, regional

To support more research on the access to and quality of services for vulnerable

the EU Drug Strategy and Action Plan â€“ in international contexts and settings.

national data to fill the gaps in our knowledge.

expenditures on drug policy in member states. and penal impact of current drug policies.

and national level) on legal regulation of cannabis.

populations, such as migrants/ethnic minorities, women, prisoners, young and ageing people. 6.

To support and/or conduct more qualitative research on patterns of drug use to

serve as a basis for the development and adjustment of innovative interventions and policies.

48 | CIVIL SOCIETY VIEWS ON THE IMPLEMENTATION OF THE EU ACTION PLAN ON DRUGS

To MEPs:

To support the budget plan of the European Commission to provide two

sustainable funding mechanisms on drug policy interventions (European Social Fund + and Internal Security Fund). 2.

To keep drug policies on the agenda of the EU Parliament and cooperate with

the Civil Society Forum on Drugs in monitoring and evaluating the implementation of the EU Drug Strategy and Action Plan.

To Member States:

To adopt evidence-informed and human rights-based approach in developing

national drug strategies and action plans, including through studies on health, social and penal consequences of current drug policies. 2.

To fill the gaps in funding and political support for services that were perceived

To improve the quality of services by implementing minimum quality standards

to have very low accessibility and availability according to the CSF report.

for demand reduction in the national level and provide adequate support and training to service providers to meet the demands of these standards. 4.

To improve the access to and quality of alternatives to coercive sanctions, as well

as remove barriers to access by training law enforcement professionals and, where necessary, changing criminal laws. 5.

To assess the needs for demand and harm reduction services in prisons and

provide access to all needed services that are available in the community, as well as ensure the continuity of services when entering or leaving prisons. 6.

To create formal mechanisms to involve civil society in drug policy decision

To recognise and take into consideration the voice of people who use drugs,

making in a meaningful way in local and national level.

including creating spaces and mechanisms for their involvement in policy-making at its various levels. 8. 9.

To improve the training of professionals in the field of demand and harm reduction. To assess the needs of specific vulnerable populations and, where appropriate,

provide funding for specific services to reach out these groups.

REPORT BY THE CIVIL SOCIETY FORUM ON DRUGS | 49