2009 Annual Report: The Czech Republic Drug Situation

SUMMARY OF THE ANNUAL REPORT

The preparation and enforcement of the national drug policy is the responsibility of the Government of the Czech Republic. Its main counsellingbody for drug-related issues is the Government Council for Drug Policy Coordination, which met three times in 2009. In the first half of 2009, as part of its EUpresidency, the Czech Republic led the Horizontal Drugs Group, a working group of the EU Council.

2009 was the last year of the implementation of the National Drug Policy Strategy for the Period 2005-2009 and the respective Action Plan for the period 2007-2009. All 14 regions had drawn up their regional drug policystrategies in 2009 (in the Pilsen region, drug issues are incorporated into the Policy Document on the Prevention of Crime and Socio-pathological Phenomena). At the turn of 2010 both national strategic documents were subjected to evaluationand new strategies for the forthcoming period were prepared.

The evaluationof the 2005-2009 National Strategy was pursued on an internal basis. In addition to assessing the results (objectives), the evaluation process also focused on the phase of the strategy’s articulation and implementation. The results showed that three strategic objectives had been achieved: the number of problem users of illicit drugs had been kept relatively stable, the rate of infectious diseases and other health risks among drug users remained low, and the network of services for drug users had been maintained. On the contrary, the experimental use of drugs continued to rise and efforts to stabilise or reduce drug consumption and the availability of drugs failed. It turned out that the character and potential of activities in individual areas of the action planand also the level of their successful implementation corresponded with the accomplishment of the respective strategic objectives. Shortcomings were identified in inter-agency coordinationand liaison. The evaluation also concluded that the drug policyhad faced a shortage of financial and human resources in the recent past.

In May 2010 the Government approved the new National Drug Policy Strategy for the Period 2010-2018, which builds upon the previous strategy, but is different from it in being conceived as a long-term vision providing for the next nine years. The 2010-2018 National Strategy defines four key objectives: (I) to reduce the level of experimental and occasional drug use, particularly among young people; (II) to reduce the level of problem and intensive drug use; (III) to reduce potential drug-related risks to individuals and society, and (IV) to reduce drug availability, particularly to young people. The Strategy will be complemented with three-year action plans.

A new Penal Code became effective on 1 January 2010. It includes significant changes in how to address illegal drugs. In particular, the changes concern drug possessionfor personal use, where drugs are differentiated according to their social and health risks. In comparison to the previous sentencing guidelines, a lower punishment range will apply to the possession of cannabisin a quantity greater than small; other types of drugs will carry stricter sentences. Another significant change is the new provision concerning the illegal cultivation of plants and mushroomscontaining a narcotic or psychotropic substance. This activity will be covered by less strict sentencing guidelines than the production of drugs. In addition, the cultivation of a small quantity of plants or mushrooms for personal use will now be a misdemeanour. By virtue of two of its regulations, the Government determined drug quantities greater than small, as well as greater-than-small quantities of plants or mushrooms containing narcotic or psychotropic substances. This is a crucial change, as until now specific quantities were only accounted for by internal regulations intended for the police and public prosecutors. The Government regulations are generally binding legal rules which are also followed by courts in their decision-making.

Labelled public expenditure on drug policyreached a level of CZK 607.5 million (€ 22,973 thousand) in 2009. This amount included CZK 375.4 million (€ 14,196 thousand) provided from the state budget, and the regions and municipalities contributed CZK 172.6 million (€ 6,528 thousand) and CZK 59.5 million (€ 2,249 thousand), respectively. In comparison to 2008, total expenses showed a nominal increase on all three levels by 1.7%; on the central level, there was a decrease in expenditure on the part of all the ministries and central agencies under scrutiny, with the exception of the Ministries of Justice and of Labour and Social Affairs and the National Drug Headquarters of the Police of the Czech Republic. On the regional level, there was a slight increase in aggregate year-on-year expenditure; a significant increase was recorded in the region of South Moravia, while the region of Central Bohemia reported a marked decline. Over one third of regional expenditures, however, was earmarked to finance sobering-up stations. The aggregate of funds expended by municipalities experienced a slight decline. Out of a total amount of CZK 607.5 million (€ 22,973 thousand), CZK 177.2 million (€ 6,699 thousand) was earmarked for treatment, including the sobering-up stations (4% less than in 2008), CZK 175.0 million (€ 6,616 thousand) for harm reduction(10% more), CZK 154.7 million (€ 5,851 thousand) for lawenforcement (2% more than in 2008), CZK 54.0 million (€ 2,078 thousand) for primary prevention(6% less), and CZK 31.8 million (€ 1,201 thousand) for aftercare(28% more). These labelled expendituresdo not include most of the resources spent on repressive activities intended to curtail drug crime, such as those pursued by the police, public prosecutors, courts, and the prisonsystem, or the cost of treatment covered by health insurance (it is estimated that approximately CZK 200 million (€ 7,563 thousand) from health insurance is used annually in the Czech Republic to cover the treatment of non-alcoholdrug dependency – for more details see the ‘selected issues’ section). The long-term decline in the funds available to the Government Council for Drug Policy Coordinationcontinued in 2010, which led to the providers of drug services publicising the initiative We Have Had Enoughof This (“Máme toho dost!”). Its purpose was to
bring attention to the problems concerning the provision of subsidies and underfunding in general which endanger the quality and even the very existence of the services.

No school-based studylooking into the issue of drugs was conducted in the Czech Republic in 2009 (the latest results were provided in the 2008 Annual Report). However, a few small-scale surveys and projects focusing on the adult population were carried out. Taking into account the findings of the studies conducted with the adult population in the years 2008-2009, the lifetime prevalenceof the use of cannabis, ecstasy, pervitin, and cocaineamong the Czech adult population is 30%, 5-10%, about 4%, and 2%, respectively. The prevalenceof the last-year use of cannabis, ecstasy, pervitin, and cocaine among Czech adults reached the respective levels of 11-15%, 3-4%, about 1.5%, and about 0.5%. The use of cannabis, ecstasy, pervitin, and cocaine by young adults (aged 15-34) in the last year showed prevalence rates of 22-28%, 3-8%, up to 3%, and about 0.5-1.5%, respectively. Surveys carried out at dance events and in other nightlifesettings suggest dramatically higher prevalence rates of illicit drug useamong this specific subpopulation of young adults: in addition to cannabis, they tend to use mainly ecstasy, followed by pervitin, cocaine, and hallucinogens.

The year 2009 saw a significant rise in the mean estimate of the number of problem drug users, which reached the level of approximately 37.4 thousand. Pervitin users (approximately 25.3 thousand) made the greatest contribution to the increase. The number of injecting drug users also rose (to about 35.3 thousand). In addition, there was a slight increase in the number of opiate users (to 12.1 thousand), including an estimated 7.1 thousand heroinusers and 5.1 thousand Subutex® users. As confidence intervals for the estimates from recent years overlap, the observed increase should be interpreted with caution. Nevertheless, there was a statistically significant year-on-year increase in the numbers of problem pervitinusers and injecting drug users. Traditionally, Prague and Ústí nad Labem are the regions showing the highest rates of problem drug users, as well as opiate users. Of all the regions, in addition, Ústí nad Labem has the highest estimated number of problem pervitin users. While the capital city reported a decline in the number of problem drug users in its territory for the first time since 2005, the estimated number of problem users in the region of Ústí nad Labem rose.

The relatively favourable situation concerning the occurrence of infections among (injecting) drug users continued in 2009; HIVseroprevalence remains far below 1%. In 2009 seven HIV positive people who may have contracted the virus through injecting drug use were newly identified, which is less than in 2007 and 2008. Thus, the reported incidenceof HIV among drug users returned to the more favourable levels experienced in the earlier years (the total incidence rate of HIV in the Czech Republic is on the rise, however, as a result of the spread of infection among gay men). The numbers of newly reported cases of HBV and HCV among injecting drug users have been declining in recent years; depending on the studysample’s characteristics and selection criteria, the prevalenceof HCV among drug users ranges from approximately 20% in low-thresholdprogrammes to 40% in prisons. The relatively highest rate of infections was recorded for incarcerated injecting drug users (for example, an HIV prevalence of over 2% was identified in 2009). However, the results need to be interpreted with caution, bearing in mind the possibility of a sampling error. The rate of injecting among pervitinand opiate users in contact with counsellingand treatmentagencies has been decreasing slightly in the long term, but for the majority of these users it is still the most common route of administration.

In 2009, for the first time, data on new cases of sexually transmitted infections among injecting drug users are available. A rising trend in the incidenceof syphilis among injecting drug users has been observed in recent years: 103 cases of syphilis among IDUs were reported in 2009 (i.e. 10% of all the cases recorded), while 17% of the individuals were found to be engaged in prostitution (mostly women).

According to a special register, the year 2009 witnessed a slight increase in the number of fatal overdoses on illicit drugs and inhalants(49 cases in total) reported by forensic medicine departments, which suggests the continuation of the slightly rising tendency already experienced in the previous year. In particular, the number of fatal opiate overdoses increased on a year-on-year basis, from 15 cases in 2008 to 20 in 2009. The rates of fatal overdoses on pervitinand inhalants showed almost no changes. After several years of no records of fatal overdoses on (new) synthetic drugs, three deaths by TMA, 4-MTA, and GHB respectively were reported in 2009. Cocaine was present in two deaths classified as pervitin overdoses. From the mid-term perspective, the growing numbers of indirect pervitin- and THC-related deaths (i.e. deaths other than by overdose, especially resulting from accidents and suicides) can be observed, although their 2009 levels remained the same as in 2008. For the first time, the Annual Report presents data on fatal drug overdoses contained in the Czech Republic’s general mortalityregister (Deaths information system). These data show a rising trend for the past three years.

The traffic police records indicate that the number and proportion of accidents caused under the influence of alcoholand drugs, as well as the number of people killed in accidents caused by impaired drivers, continued to grow in 2009. There has also been an increase in both the number and proportion of people killed in accidents caused by drivers under the influence of other drugs, although the numbers of these reported by the police still tend to be much lower in comparison to the results of autopsies on individuals killed in road accidents investigated at forensic medicine departments.

In the Czech Republic, drug users and addicts may seek help from a network of services providing a wide range of easy-to-access interventions. The network of helping agencies experienced no major changes in 2009. There was a decrease in the capacity of sheltered housing provided as part of after-care programmes for drug users. Early assessment and intervention tools aimed especially at childrenand young people have been introduced into treatmentand counsellingpractice at a growing rate in recent years.

There was a year-on-year increase in the number of drug users listed in the Register of Treatment Demands maintained by the
Public Health Service. A total of 8,763 drug users sought treatmentservices in 2009, i.e. 500 persons more than in 2008. In comparison to the previous years, a slightly declining trend has been reversed, and the numbers of treatment demands returned to their 2004 and 2005 levels.

Traditionally, stimulant users predominate as far as treatmentdemands are concerned. In 2009, too, they comprised the largest group among all treatment demands (59.5%), as well as first treatment demands (60.9%); the number of pervitinusers also showed the highest year-on-year increase. The second most numerous group was made up of opiate users (23.4%), while cannabisusers ranked second among first treatment demands (18.3%). The age structure perspective reveals a slight aging of the treatment demand population. While the year-on-year increase in average age is small, a rising trend is apparent from the mid-term perspective. In 2009, the average age of first treatment demands and all treatment demands was 24.2 and 25.9 years, respectively. The average age of people seeking treatment for the first time has increased by more than three years over the past decade and that of all the people demanding treatment has risen by 3.5 years. Women continue to account for one third of treatment demands. Traditionally, the region of Ústí nad Labem and the Capital City, Prague, report the highest relative prevalenceand incidenceof people demanding treatment.

There was also an increase in the number of drug users reported by psychiatric outpatient facilities. As regards the three largest user groups, there were slightly more opiate (heroin) users and fewer stimulant (pervitin) users, and polydrug users showed a more significant rise in their numbers.

The year 2009 also experienced a growing number of illicit drug users admitted to psychiatric inpatient facilities, which resulted from an increase in the number of admissions to psychiatric hospitals. First and foremost, this increase was due to patients being admitted for disorders caused by polydrug use; the numbers of opiate and stimulant users who were hospitalised dropped.

The number of patients in substitution treatmenthas also been on the rise. This may apply to both specialised centres and other physicians who prescribe products containing buprenorphine(Subutex® and Suboxone®); however, treatmentwith these preparations has not been fully included in the substitution register. In Prague, especially, the diversion of Subutex® to the black market occurs.

A wide range of counsellingand treatmentservices is available to drug users in prisons. Nine (out of a total of 36) prisons provided methadonesubstitution treatmentin 2009. The care of drug-using inmates was complemented by additional services delivered by 15 non-governmental organisations in 30 prisons.

The number of low-threshold facilitiesfor drug users has oscillated around 100 on a year-on-year basis. In recent years, however, a significant increase in the number of clients engaged with these low-threshold programmes has been observed. It is estimated that approximately 70% (up to 80% in Prague) of problem drug users maintain contact with these services. There has also been a continuous rise in the number of contacts with IDUs and the amount of injecting equipment and paraphernalia exchanged, although the year-on-year increase in the amount of injecting material distributed in 2009 did not reach the previous years’ levels; almost 4.9 million hypodermic needles and syringes were distributed in 2009.

Although the low level of availability of testing for infectious diseases and the very low degree of tests performed on the population of problem drug users may be seen as an enduring negative trend, the data from the past two years suggest that the negative trend is slowly being reversed. In 2009 and 2010 the staff of low-thresholdservices, particularly in Prague, repeatedly referred to clashes between street workers and police officers and the complex nature of work with ethnic minorities. In view of drug users’ presence on the
open drug scene and the related problems in terms of public order, ideas promoting the establishment of drug consumption rooms and the installation of injecting equipment vending machines in Prague were raised.

There has been a long-term increase in the number of individuals arrested, prosecutedfor, and chargedwith drug-related criminal offences. Specifically, more people were prosecuted for and charged with drug possession(Section 187a), while fewer people were adjudged to have promoted drug use(Section 188a). The most common drug-related charges are associated with pervitin, cannabis, and heroin; currently, the involvement of cannabis in drug offences is on the rise, while that of pervitin has dropped. The regions reporting the highest numbers of individuals pending prosecution include Moravia-Silesia, Ústí nad Labem, and the Capital City, Prague. From the long-term perspective, approximately 90% of the people arrested and prosecuted for drug-related offences are finally indicted. Among those convicted, an increase in the proportion and the number of offences of drug possession under Section § 187a can also be noted. As far as the structure of the sentences is concerned, the situation remains stable: for the past three years, unsuspended prisonsentences have accounted for about 30%, while suspended sentences comprised 50% of the sanctions imposed. The highest number of sentences is awarded in relation to drug production and trafficking(Section 187) and in connection with pervitin.

Since 2009 misdemeanours involving drug possessionfor personal use (and since 2010 also misdemeanours involving the cultivation of plants or mushroomscontaining a narcotic and psychotropic substance for personal use) have been dealt with by the local authorities of municipalities with extended competences instead of the Police of the Czech Republic. The relevant 2009 data were not available at the time of writing of this report.

According to expert estimates, drug users are annually responsible for approximately 71-74 thousand criminal offences, which accounts for approximately one fifth of all the offences detected in the Czech Republic (about 345 thousand per year). Their most common crime is vehicle burglary. Other estimates indicate that approximately 14% of the new clients of the Probation and Mediation Service of the Czech Republic have committed a drug-related criminal offence. The police records show that 22.2 thousand offences were committed under the influence of alcohol, while 2.3 thousand crimes occurred under the influence of non-alcohol drugs. The largest number of criminal offences on the part of non-alcohol drug users was committed under the influence of pervitinand cannabis. On the basis of a rough estimate in relation to the total number of detected crimes, the offences committed annually under the influence of alcohol may be about 62 thousand (18% of all the crimes detected) and those committed under the influence of non-alcohol drugs about seven thousand (2%).

Cannabis is the most widely available drug in the Czech Republic. In this country, cannabisis frequently grown in artificial conditions which contribute to its higher THCcontent. 117 seizures resulted in the confiscation of 33,427 cannabis plants, the largest quantity since 2006. The number of large-scale indoor cannabis growing sites detected is increasing (84 in 2009). Pervitin remains the second most frequently seized drug, although the year 2009 experienced the detection of the smallest number of pervitin-cooking laboratories in the past three years (342). From May 2009 pharmacies were restricted in terms of their supply of medicines containing pseudoephedrine, which is used as the main precursor in the production of pervitin. Although this measure led to a reduction in the sale of these pharmaceuticals in the Czech Republic, an increase in illegal imports of the products from abroad, mainly from Poland, was recorded. For this reason, measures intended to control the availability of medicines containing pseudoephedrine at the European level have been recommended.

Cocaine has become a well-established stimulant drug, particularly in the nightlifesetting. Twenty-six cocaineseizures were recorded. The total quantity of 12.9 kg makes it the second largest amount of cocaine seized in the past four years. The number and the total volume of heroinseizures have remained relatively stable.

The fewest seizures and the smallest quantity of the drug seized in the past four years were recorded for ecstasyin 2009; tablets containing mCPP as the active ingredient have a significantly larger share of the Czech market than those containing MDMA. On the dance scene, in particular, growing interest in mephedrone was observed in 2009. The emerging popularity of this stimulant substance may be partly explained by the lack of ecstasy tablets containing MDMA and by mephedrone, like a number of other (new) synthetic drugs, not being controlled, or banned, in many countries. This also applies to the Czech Republic, where the handling of mephedrone and other (new) synthetic drugs may, under specific circumstances, be prosecutedas the offence of promotion of drug use, but it cannot be classified as drug production and trafficking.

According to the drug marketestimates, almost 19 tonnes of cannabis, 4.7 million tablets of ecstasy, and one million doses of LSDwere consumed in the Czech Republic in 2009. 550 kg of 70% cocainewere imported into the Czech Republic and almost a tonne of cocaine of 45% purity was consumed. 4.2 tonnes of 80% pervitinwere manufactured and 4.4 tonnes of 70-80% pervitin were consumed. 330 kg of 40% heroinwere imported into the Czech Republic and 1.3 tonnes of heroin of 10% purity were consumed.

The prices of most common drugs remained stable in 2009, although a slight increase in both the average and most frequent prices for cannabiscould be observed at the retail level.

The Report concludes with three chapters on selected issues, including treatmentguidelines, drug use-related mortality, and the cost of drug-related treatment.

The first chapter addresses the treatmentguidelines (standards) covering the area of the treatment of drug users in the Czech Republic. These standards are tools guiding the process of the maintenance and assurance of the quality of services, which makes it possible to assess whether, and to what extent, a specific service is provided in good quality. There are several types of guidelines: training guidelines, guidelines for centres, facilities, and programmes, case- and diagnosis-based procedural guidelines, methodological guidelines, and ethical guidelines. The Czech Republic has elaborated the type of guidelines (standards) governing the operation of centres, facilities, and programmes. Such guidelines are primarily represented by the so-called Certification Standards of the Government Council for Drug Policy Coordination. Compliance with these standards is tested as part of the certificationprocess. Conceived as an inter-agency instrument, these guidelines cover a wide range of health, social health, and social services. The Standards for Quality in Social Services of the Ministry of Labour and Social Affairs and the standards for primary drug preventionprogrammes developed by the Ministry of Education, Youth, and Sports also fall under this category. Czech examples of guidelines for case- and diagnosis-based procedures include the Recommended Treatment Procedures for Addiction Disorders and Pathological Gambling developed by the Psychiatric Society of the J.E. Purkyně Czech Medical Association. The only Czech methodological guidelines in the field of addiction, in fact, are the Health Ministry’s standards for substitution treatment.

The purpose of the second selected issue is to provide information about mortalityrelated to drug useand its significance in terms of public health. This chapter presents an overview of the mortality (cohort) studies among drug users carried out hitherto in the Czech Republic and summarises their results. Drug users in the Czech Republic show a higher mortality rate in comparison to their peers in the general population. The available studies suggest that their relative risk of death is at least 10 times higher than is the case for the comparable general population age group. Women and very young adults show the highest risk, given the respective low mortality rates for these demographic groups in the general population. The most common cause of death of drug users (in 75% of cases) includes external (violent) causes of death and intoxication. In proportion, the highest risk of death occurs shortly after the onset of (problem) drug use, which is usually at a very early age.

The third chapter on a selected issue provides an overview of the cost of drug-related treatmentin the Czech Republic, which is addressed in the context of primary preventionand harm reductionand structured according to types of treatment interventions. It covers the costsincurred in relation to addiction and drug usecounselling, treatment, and after-care, not those of the treatment of health consequences and complications, such as infectious diseases and injuries, brought about by drug use. In the Czech Republic, drug addiction treatment is funded using health insurance, public resources (ministries, the Government Council for Drug Policy Coordination, regions, and municipalities), services’ own resources, and private resources (clients’ and patients’ fees, contributions, and sponsorship). The data reflect the 2007 situation, as more recent data concerning the expenses of the General Health Insurance Company spent on drug-related treatment were not available for analysis. The identified costs of prevention, harm reduction, and drug use treatment and aftercarein the Czech Republic in 2007 amounted to CZK 741.1 million (€ 28,024 thousand); CZK 53.5 million (€ 2,023 thousand), CZK 148.9 million (€ 5,631 thousand), and CZK 505.9 million (€ 19,130 thousand) were spent on prevention, harm reduction, and treatment and aftercare, respectively. The most resources to fund treatment and aftercare, CZK 204.4 million (€ 7,729 thousand), were provided by health insurance. Treatment and aftercare receives less financial support from the budgetof the Government Council for Drug Policy Coordination than harm reduction programmes, but significantly more than primary prevention. When different types of programmes covering the domain of treatment and aftercare are compared, the greatest proportion of all the resources is earmarked for institutional treatment. The resources spent on abstinence-oriented outpatient treatmentrank second, followed by substitution treatmentin third place. The smallest amount of resources is dedicated to treatment in therapeutic communities and aftercare. An additional comparison of treatment interventions indicates that therapeutic communities and aftercare programmes, which are not covered by health insurance, as they do not have the status of a healthcare facility, have the relatively smallest amount of financial resources to use. When the cost is calculated in relation to the number of clients, therapeutic communities turn out to be the most expensive, although the average period of treatment in a community is much longer than in an institutional setting.


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