Alexis Goosdeel became the new Director of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) in Lisbon, Portugal, on January 1, 2016.

Drugreporter: How would you sum up Europe’s current drug situation?

Alexis Goosdeel: I would begin by saying that Europe’s use and marketing remain resilient. We are currently facing new health risks posed by high-potency products; the continued emergence of new psychoactive substances (NPS); as well as changing patterns of drug use. We also have concerns over rises in overdose deaths in some countries and the threats posed by internet drug markets.

Over 88 million adults, just over one in four 15- to 64-year-olds in the European Union, are estimated to have tried illicit drugs at some point in their lives.

As we outlined in our European Drug Report 2016: Trends and Developments, there is now a need for Europe’s drug policy agenda to embrace a broader and more complicated set of policy issues than in the past.

DR: If you were to single out one trend this year, what would it be?

AG: We are of course observing many trends, across many different areas, and it is difficult to pinpoint just one. A prominent trend this year, which we underlined in our annual reporting, is the return of MDMA (often sold as ‘ecstasy’) as a stimulant drug of choice for young people in Europe.

Around 2.1 million young adults (15–34 years) report having used MDMA in the last year (1.7% of this age group). There are indications that MDMA is becoming more popular, both with established stimulant consumers and with a new generation of young users. There are also signs that it is no longer a niche or sub-culture drug used in dance clubs, but is now being used by a wider range of young people in more mainstream nightlife settings, such as bars and parties.

The revival of MDMA brings with it a need to rethink existing prevention and harm-reduction responses, in order to target a new population of users who may be using high-dose products, without fully understanding the risks involved. Overdoses and even deaths, associated with this drug, have been reported. This is particularly worrying since MDMA is moving more into the mainstream and is increasingly available via online markets.

DR:: You mentioned the emergence of new psychoactive substances. How many were detected in the past year, and what do we know about them?

AG: In 2015, 98 new psychoactive substances (NPS) were reported for the first time in Europe (101 in 2014), bringing the total number of new drugs monitored by the EMCDDA to 560. The list of new substances reported was dominated by synthetic cannabinoids and synthetic cathinones.

Together, these two groups accounted for almost 80% of the 50,000 NPS seizures in 2014 and over 60% of the 4 tonnes seized.

We monitor the harms related to new drugs in Europe via the EU Early Warning System (EWS) on new psychoactive substances. These harms vary in nature, but can be serious, including acute poisoning and even deaths. In 2014 alone, the EMCDDA issued 34 public health alerts to the Member States relating to the use of NPS.

Synthetic cannabinoids, sold as ‘legal’ substitutes for cannabis, can be highly toxic, and mass poisonings have been reported, for example in Poland. In February 2016, the EMCDDA issued a warning concerning MDMB-CHMICA, a synthetic cannabinoid associated with 13 deaths and 23 non-fatal intoxications in Europe since 2014. Synthetic cathinones are sold as ‘legal’ replacements for stimulants, such as amphetamine, MDMA and cocaine. The synthetic cathinone alpha-PVP, a potent stimulant, has been linked to almost 200 acute intoxications and over 100 deaths since 2011.

Concerns are also growing over the number of new synthetic opioids detected. A total of 19 new synthetic opioids, including 11 variants of fentanyl, have been detected since 2009. Many variants of fentanyl are highly potent, and may be sold as heroin to unsuspecting users, posing a risk of overdose. Responding effectively and rapidly to the sale of NPS, some of which are found to be highly toxic, is a major challenge. This is especially the case since young consumers may unwittingly be acting as human guinea pigs for substances whose potential health risks are largely unknown.

DR: How can we respond to these drugs?

AG: This year, we marked the International Day Against Drug Abuse and Illicit Trafficking on 26 June, with the release of our first study on health responses to NPS, in the light of hospital emergencies and the rising demand for specialist drug treatment. The initial responses to new drugs in Europe have largely been regulatory, focusing on legislative tools to tackle supply. But as the phenomenon evolves, it is becoming critical that we formulate and implement effective public health responses to the use of these substances. The significant number of annual detections of these drugs, and associated harms, calls for the continuous assessment and development of appropriate services for users at risk.

Our findings show that existing interventions addressing drug use can be adapted to deliver a comprehensive health response to NPS-related harms. The approaches recommended in the study are therefore largely based on existing responses, but adapted to reflect: unique user group needs; the structural, cultural and social contexts of use; and new opportunities for engaging recreational NPS user groups.

DR: Regarding overdoses, why and where are we seeing increases?

AG: At least 6,800 overdose deaths, mainly related to heroin and other opioids, are estimated to have occurred in the EU in 2014, slightly up on the previous year’s figure. The worrying rises in these deaths are reported in countries with long-established opioid problems such as Ireland, Lithuania, Sweden and the UK.

The reasons behind these rises in fatal overdoses are unclear, but a number of factors may be involved, including: increased heroin availability, higher purity, ageing users, and changing consumption patterns, including the use of synthetic opioids and medicines. Overdoses are most commonly reported amongst older opioid users (35–50), but increases in overdose deaths are also seen among the under-25s in some countries, such as Sweden - which of course warrants closer scrutiny. A number of countries now provide the overdose-reversal drug naloxone to opioid users via community schemes.

Although heroin remains the most commonly used opioid, synthetic opioids are increasingly misused and there has been a rise in the number of countries reporting synthetic opioids as the primary drug used by those entering treatment. Synthetic opioids used in substitution treatment (for example methadone and buprenorphine) are also regularly found in toxicology reports, and these substances are associated with a substantial proportion of drug-related deaths in countries such as Ireland, France, Finland, UK.

DR: In your European Drug Report this year, you underlined the potential for new methods to complement your more traditional monitoring of the drug situation. What are these?

AG: Here we were referring in particular to the potential for hospital emergency data and wastewater analysis to enrich our understanding of the drug problem and to complement traditional monitoring methods. The EMCDDA adopts a multi-indicator approach to drug monitoring, on the principle that no single measure can provide a full picture of the situation.

Data from hospital emergency units can provide us with a unique insight into acute health harms related to drug use, and can improve our understanding of the drugs problem, by broadening the scope of our monitoring. Emergency data not only complement routine indicators of high-risk drug trends and related harms, but also act as early-warning signals on new substances and patterns of use.

In August this year, we published a new report on hospital emergency presentations and acute drug toxicity in Europe. Data from hospital emergency departments reveal that every year in Europe, thousands of individuals experience drug-related poisoning and other harms, requiring some form of medical assistance.

Those affected are mainly young adults (20–39 years), and predominantly male, and we see that heroin is still No. 1 on the top 20 list of drugs involved. The report also shows a recent rise in hospital emergency presentations cases linked to NPS. The report is based on an analysis by the European Drug Emergencies Network (Euro-DEN Plus), which monitors drug-related emergency presentations in 20 ‘sentinel’ hospitals in 14 European countries. The EMCDDA participates in the network’s Steering Committee. In its first two-year data-collection period (October 2013 to September 2015), the network recorded 10,956 drug-related emergency presentations, including 49 deaths. Continued monitoring in emergency settings will help us assess the public health impact of acute drug toxicity in Europe, develop appropriate healthcare and prevention activities, and provide crucial input to our risk assessments of new psychoactive substances.

As for wastewater analysis, this is a rapidly developing scientific discipline with the potential for monitoring near-real-time data on geographical and temporal trends in illicit drug use. By sampling a known source of wastewater, such as a sewage influent to a wastewater treatment plant, scientists can estimate the quantity of drugs used in a community by measuring the levels of illicit drugs and their metabolites excreted in urine.

Wastewater analysis is a valuable additional tool in our epidemiological toolkit and one which can provide timely information on a wide spectrum of substances. Its ability to deliver almost real-time data on drug use patterns is particularly relevant against the backdrop of an ever-shifting drugs problem. By detecting changes in drug use patterns, both geographically and over time, it can help health and treatment services respond better to emerging trends and changing treatment needs. Here, the EMCDDA collaborates with the Europe-wide SCORE network.

DR: You have spoken this year on the subject of drug-related hepatitis C. What is the latest news in this area?

AG: Around 115 million people worldwide have been infected at some point in their life by the hepatitis C virus (HCV). Two-thirds of these are estimated to be chronically infected, over 5 million of them within the European Union. The infection is highly prevalent among people who inject drugs, who can contract HCV through the sharing of needles, syringes and other injecting equipment. This year we marked World Hepatitis Day with a report which looks at new opportunities for the effective prevention and treatment of the disease, including the use of a new generation of medicines.

HCV infection levels among people who inject drugs range from 15% to 84%, with many studies showing 50% or more infected. Initial infection with HCV is often asymptomatic and many people with an injection history are unaware that they are carrying the virus, leading to the disease being referred to as a ‘hidden epidemic’. If left unresolved, the infection can lead to chronic liver disease, cirrhosis, cancer and death.

Failure to address HCV infection among people who inject drugs will mean considerable costs in the future, both to individuals and to health budgets. There are now grounds for greater optimism in preventing and treating the disease. This is thanks to the combination of opioid substitution treatment and needle- and syringe-exchange programmes, with new pharmacological options for HCV, and a growing confidence in our ability to deliver effective treatment in the community to people who inject drugs. I believe that in Europe, we now have an opportunity to make real and sustained progress in this area. By combining treatment with adequate prevention and harm-reduction measures, we have the necessary tools to control this epidemic.

DR: What would you say are the agency's most important tasks or challenges?

AG: One of our most important tasks is to prepare for future drug phenomena. Over the last 20 years, much has changed in the extent and nature of the drugs problem. In 1995, when the agency embarked on its mission, Europe was in the midst of a heroin epidemic, with all its public health risks and consequences. In 2016, the complexity of the drugs problem has increased, with many of the substances monitored today virtually unknown when the agency was first established. In most EU Member States, open drug scenes are now less common than in the past. This has caused the drug phenomenon to be less visible and possibly less of a (political) priority, which is also a challenge for the agency. Today, we also have the Internet playing a large role in the buying, dealing and trafficking of drugs, as well as in exchanging information among users. We highlighted the issue of online drug markets earlier this year in the second EU Drug Markets Report, published in collaboration with Europol.

Another major challenge for the agency is the changing institutional environment. The development of the EMCDDA was decided by 12 EU Member States in 1993, and its operations started in 1995 with 15 EU members. Currently, there are 28 Member States, plus members Turkey and Norway. Additionally, there is collaboration with Western Balkan- and EU neighbouring countries. Furthermore, there have been changes and revisions to several EU treaties, as well as changes in EU policies regarding drug phenomena and there is increased pressure on EU institutions to deliver results.

The third challenge would be the evolution of the EMCDDA itself. Whereas the agency started out with only three or four staff members, the staff now consists of around 100 employees. Over the years, there have been increases in tasks, budget and posts for new staff members.

Between 2014 and 2018, however, the EMCDDA, like other EU institutions, will have lost around 10% of its work force and budget, thereby still facing the consequences of the 2008–2009 financial crisis.

Nevertheless, the agency has developed into an institution which is able to cover more ground, as well as to work more in-depth on the European drug phenomenon. At this moment, I think the EMCDDA is at the height of its reputation. We are recognised more and more as a source of excellence and as an objective and neutral source of information on drugs.

DR: What about your long-term strategy?

AG: Currently, a long-term strategy is being prepared for EU Horizon 2025. I will be proposing to the EMCDDA Management Board that we concentrate the activities of the agency on the needs of its three main customers: the EU institutions, national decision-makers and professionals working in the drugs field. In order to achieve this, there is a need to shift the role of the agency from being an information-provider, to becoming progressively a service-provider, as stakeholders are in need of analyses of the currently available information. The opportunity for added value for the EMCDDA lies in added value for its customers.

The interview was made by Nadine von Gelder