Jane Mounteney

Fentanyls: Are we missing the signs? Highly potent and on the rise in Europe

Fentanyl is a synthetic opioid analgesic historically used as a pain reliever and an anaesthetic. Recent concerns have arisen around the illicit use of fentanyl and its analogues in a number of European countries, linked to their high potency and associated risk of fatal overdose. Evidence has been emerging from Estonia for over a decade of entrenched patterns of fentanyl use, including injection of the drug and hundreds of overdose deaths. More recently, reports indicate that both fentanyl and 3-methylfentanyl (TMF) have been marketed as a replacement for heroin in European countries (e.g. Bulgaria, Slovakia) affected by heroin shortages. In addition, Germany, Finland and the United Kingdom, reported new outbreaks of fentanyl-related deaths. This combination of increasing mortality data alongside law enforcement intelligence suggesting both diversion and illicit production of fentanyls, prompted wider investigation using a targeted multi-source data collection exercise and analysis. This identified that in the European context, fentanyls are low use but high risk/harm substances. Evidence shows that Estonia stands out as having an endemic problem, while the use of fentanyls in other European countries appears to be geographically localised. Developments in illicit supply of fentanyls reflect the complexity of Europes contemporary drug market: manifesting illicit production and use, the diversion and misuse of medicines, and the online sale of non-controlled new psychoactive substances. Likewise effective and integrated responses will need to address fentanyl production, diversion as well as ensuring the availability of harm reduction measures to users.

Drug Information Systems, Early Warning, and New Drug Trends: Can Drug Monitoring Systems Become More Sensitive to Emerging Trends in Drug Consumption?

Drug Information Systems (DIS) are called upon to provide an early warning of emerging trends in drug use. However, little theoretical attention is directed toward exploring conceptual issues in this area. In this paper a typology of existing DIS is offered. Among the features that distinguish DIS are their structure (human network or organization systems) and the range of information sources used. Indicators of drug use can be placed on a continuum of sensitivity ranging from leading edge indicators to lagged indicators. Sensitivity implies volatility as sensitive indicators also react to fluctuations that do not become trends. DIS conventionally are largely reliant upon lagged indicators. What is required are DIS that combine a critical information processing function with the ongoing systematic collection of data from a range of data sources. [Translations are provided in the International Abstracts Section of this issue.]

Truancy, alcohol use and alcohol-related problems in secondary school pupils in Norway

This study focuses on a vulnerable group of pupils often missed by mainstream school surveys. It explores alcohol use and alcohol-related problems for a sample of truants of secondary school age, comparing behaviours with a school-based sample from the same geographical area. Analyses are based on a survey among truants (n = 107) and a school survey (n = 3702) undertaken in Bergen, Norway. When compared with mainstream pupils, the truants reported an earlier alcohol debut and a higher frequency of drinking. They reported significantly higher levels of binge drinking (6+ units). Truants were four times more likely to report regular drunkenness and twice as likely to report problems associated with their alcohol consumption. In the truancy sample, boys were more likely to engage in regular and excessive drinking, while girls reported higher levels of problems linked to their drinking. Results suggest that higher levels of truancy were related to more frequent drinking, drunkenness and alcohol-related problems. There are strong indications for early intervention activities directed at truants, and registration of truancy in itself could be a simple and effective way of identifying pupils at risk of a wide range of social and health problems, including high levels of alcohol use.

Challenges of Reliability and Validity in the Identification and Monitoring of Emerging Drug Trends

There is increasing pressure on drug monitoring systems to achieve earlier detection and greater precision in reporting of emerging drug use trends. Such systems typically operate in settings where government interest and the drug use trends themselves can be fluid. To achieve the goal of informing timely policy and practice responses in this environment, drug use monitoring systems must be flexible and responsive, as well as reliable and valid. This paper explores three interrelated areas relevant to trend monitoring that can benefit from a clearer focus in terms of increasing validity and reliability: the research paradigm to which systems adhere; the selection of sources or drug use indicators utilized by systems; and the process of analysis used by systems to ensure valid results. The reliability and validity of currently utilized drug use related indicators is discussed, with a focus on the validity of data sources as measures of emerging drug use trends. The relevance and utility of current descriptives such as “lagged” and “leading edge” indicators are assessed. Five dimensions, against which the validity of drug use indicators may be assessed in a trend-monitoring context are proposed as an alternative. Faced with a lack of clear conceptual frameworks underpinning and driving monitoring systems, it is argued that a pragmatic research paradigm can be adopted as a basis for guiding selection of indicators and helping to make explicit the concurrent or supplementary triangulation and analysis procedures on which valid results are necessarily founded. The current trend of using triangulation as the primary means of ensuring the validity of systems is critically reviewed and a challenge is issued to the field to make the analysis process more overt. No external funding was received for this article.

The European drug landscape in 2013 – Highlights from the EMCDDA's European drug report

May 2013 saw the publication of the first European Drug Report (EDR), the European Monitoring Centre for Drugs and Drug Addiction’s (EMCDDA) comprehensive and multi-dimensional package providing information on European drug trends and developments (European Monitoring Centre for Drug and Drug Addiction, 2013a) alongside focused analyses and country level data. This article presents highlights from the EDR package, which can be accessed in its entirety at: www.emcdda.europa.eu. Taking a broad view of the European drug landscape, the 2013 EDR reveals a number of positive developments including record levels of treatment provision accompanied by signs of erosion in injecting, new heroin use and drug-induced deaths. It also identifies a partial move away from the historical focus on small number of plant-based substances that have been transported long distances to Europe’s consumer markets. By contrast, a range of synthetic drugs and new psychoactive substances are increasingly detected, both on the illicit drug market and in the context of non-controlled substances. Cannabis continues to be Europe’s most used illicit drug and despite some evidence of decreasing trends, especially in countries with a long and established history of high prevalence, its use remains high by historical standards. An estimated 15.4 million or 11.7% of young adults (aged 15–34 years) used the drug in the previous year in Europe, including about two million daily users. Problems among older chronic users are also becoming increasingly recognized and cannabis is now the most common drug reported by clients entering specialized drug treatment for the first time. There is also increasing diversity in the types of cannabis products available, with resin and herbal cannabis, sometimes of high potency, accompanied by the recent emergence of synthetic ‘cannabis-like’ products. Cannabis use continues to be an important focus for prevention work with young people and a growing interest in the use of environmental prevention strategies, which have shown success in addressing alcohol and tobacco use, is noted. Against the backdrop of an overall increase in treatment availability for heroin users, with over 730 000 in opioid substitution treatment, indicators now suggest downwards trajectories in both use and availability of this drug. Seizures have declined in the longer term and recent market shocks or shortages have been experienced by a number of countries (Griffiths, Mounteney, & Laniel, 2012). The number of heroin users entering specialized treatment for the first time also continues to fall, less report injection of the drug, and in many countries they constitute an ageing population. A concomitant and welcome decline in new HIV diagnoses attributed to drug injection has been observed until recently, when HIV outbreaks in Greece and Romania interrupted this positive trend (European Monitoring Centre for Drug and Drug Addiction and ECDC, 2012). This serves as a timely reminder of the ongoing need to consolidate effective harm reduction and drug treatment responses in this area. The current analysis notes a high degree of interchangeability and flexibility in Europe’s stimulant market. This is evident both at the level of production, where facilities have been seized that produce both amphetamines and ecstasy depending on precursor availability, and also at the user level, where stimulant drugs, such as amphetamines, cocaine, and ecstasy are often substituted for each other, depending on availability, price and perceived ‘quality’ (European Monitoring Centre for Drug and Drug Addiction, 2013b). Cocaine remains Europe’s most commonly used stimulant with around 2.5 million or 1.9% of last year users among young adults (aged 15–34). Overall, however, both cocaine use and supply indicators have been trending downwards in the higher-prevalence countries. A recent upturn in the popularity of ecstasy has been reported in some countries, following a period when

Monitoring emerging drug trends: Psychometrics and validity in earlier warning systems

Within the drug trend monitoring arena, there is an increasing emphasis on the need for more timely identification and reporting of new patterns in drug consumption for policy-making purposes. However, there are documented problems with establishing the reliability and validity of results from emerging drug trend monitoring systems (EDTMS), which tend to be multi-indicator and use mixed methods. The aim of this article is to present a standardised and sequential approach to EDTMS development and refinement, i.e. grounded in the key elements of psychometrics, and illustrate its application using an established city level EDTMS. A five-step process is presented and exemplified, incorporating: (1) theoretical conceptualisation of the construct to be measured; (2) score construction; (3) weighting of indicators; (4) exploration of the prospect of categories (subscales); and (5) checking for external validity. The practical application of these validity enhancing stages are demonstrated using the Bergen Earlier Warning System. For non-traditional systems operating in a fast changing environment, an iterative review and refinement process (rather than a standardised system or instrument) has clear benefits, and can be adopted to enhance validity in existing EDTMS, or be used in the development of new models.

Continued signs of resilience in the European drug market: Highlights from the EMCDDA’s 2016 European drug report

May 2016 saw the launch of the European Drug Report (EDR), the European Monitoring Centre for Drugs and Drug Addiction’s (EMCDDA) annual review of the European drug situation, incorporating situational and trend analysis, statistical data and individual country information (EMCDDA, 2016a). As in previous years (Mounteney & Griffiths, 2014; Mounteney, Zobel, & Griffiths, 2013), we present highlights from the report which can be accessed in its entirety at: www.emcdda.europa.eu. Overall, the 2016 analysis highlights a resilient European drug market, with recent survey data showing modest increases in the estimated prevalence of use of cannabis and stimulant drugs and the purity or potency levels of most illicit substances either high or increasing.