A downward trend in drug prices
Information on the price of drugs at 'street level' is difficult to obtain. Not only are the methods of determining price necessarily different from country to country, the sampling problems in producing a single representative figure for a country are considerable. More than this, the variations in the purity of the drugs purchased at street level are a constant confounder in the calculations. Nonetheless, a number of countries are able to provide street purchase price information – usually a minimum, maximum and average or median price of grams or tablets of street drugs bought – for the major relevant illicit drug types, in some countries for a number of years. Tables PPP-1 to PPP-4 present this information for 2004.
Prices are seen to vary considerably across Europe according to differences in factors such as ease of supply, geographical location and national preferences in consumption patterns. Within a country though it is possible to follow in broad terms any trend that might have developed over recent years and the present extent of data coverage allows a plausible EU-level short-term trend to be constructed. This analysis must be treated with caution: there is only partial geographical coverage, not complete EU information; moreover the trends for different drugs are based on different sets of countries; the data are incomplete through time, with sporadically missing information that has been imputed; and occasional extreme estimates suggest that data quality questions might exist for some countries.
The price at which drugs are presented to the population at large can be viewed in several ways: the actual price paid for a 'street-level' dose, or alternatively translated into pure drug equivalents, or the price trend can be viewed relative to the price of other goods over time by adjusting for the effect of general inflation. Figure PPP-3 presents street-level (‘retail’) drug prices over the years 1999 to 2004 adjusted for national inflation rates and indexed to a base of 100 in 1999. The trend is averaged over those countries able to supply data for each drug ($fn). Although adjusted for inflation the trend has not been adjusted to reflect changes in purity levels, but initial inspection of information on street-level purity suggests that, while it is erratic, there are no consistent trends over time that need to be taken into account. In spite of the many caveats associated with the data, the figure shows a clear picture of overall falling prices in real terms (i.e. inflation-adjusted prices) across the drug types presented.
Between 9 and 13 countries have contributed trends ($fn), and the average trends are driven mainly by the price trends in the countries with larger general populations. Nonetheless they broadly reflect the trends in most contributing countries with only a few exceptions, although in some cases for some drugs the downward trend only begins after the year 2000. Close support for these conclusions is provided by a parallel analysis of trends in the amounts of street-level drugs that can be bought for an average monthly salary in each country (Eurostat). In terms of nominal prices – that is, not adjusted for inflation or salaries – the trends are less consistent and not so clear-cut. Even so, they are broadly downward rather than stable or increasing, with ecstasy and cocaine mostly decreasing in price and cannabis broadly stable.
The number of countries reporting time series data here is limited, but they cover 45 % to 70 % of the general population of the EU-25 countries, and cover many of the larger drug markets. Even when extrapolation to non-reporting countries is treated with caution, the overall picture is clear: the patchwork of price information that is available suggests that falling prices in real (inflation-adjusted) terms are commonplace. These average drug price trends reflect in each case the trend in the majority of reporting countries. In many cases the fall is observed in the nominal prices too, although in several cases it is only the inflation-adjusted price that is falling. The limitations of the base data and of the crude calculation methods used for the indexes must give rise to caution in drawing conclusions and indicate a need to guard against over-interpretation of the details. Yet the broader message of cheaper drugs being available to much of the European population must be considered as clearly flagged. This preliminary analysis underlines the need for further exploration of the illicit drug market, the important questions being how the dynamics of price and consumption patterns relate for different drugs and how they respond to supply factors.
Providing syringes for drug injectors
The sharing of injecting equipment among injecting drug users is one of the principal means of transmission of blood borne infections, principally HIV and hepatitis C, in Europe. Reducing the risk of blood-borne infections among injectors is an important public health objective. Included in a comprehensive response to this problem has been the use of needle and syringe programs, which by providing access to sterile syringes and other injecting paraphernalia discourage the sharing of equipment.
Nearly all Member States report having set up needle and syringe programmes, but the extent of activities varies considerably, raising the question of whether the level of provision is sufficient in all countries. The impact of this kind of intervention will be limited by the number of syringes actually made available to the injecting population. Alongside the general prevalence of HIV and hepatitis C virus (HCV) in the injecting population, information about several specific factors is necessary to assess the impact of needle and syringe programmes, these include: the number of times a syringe is re-used, the number of times it changes hands, and the level and efficiency of any cleansing for safe re-use. Such detailed data are not usually available, and to obtain them requires specialised studies. What can be achieved through data currently available at national level is a crude calculation of the number of clean syringes available on average per injector, which can be used for assessing overall levels of service availability and as valuable input for the modelling of injecting-related risk behaviour. For nine European countries there are available recent estimates of the number of injecting drug users as well as of the number of syringes distributed through needle and syringe programmes, and for two of these countries there is additional information on syringe availability. From these data it is possible to make a crude estimation of the yearly number of syringes available per injector, calculated by dividing the reported number of syringes distributed per year in the country by the estimated number of injecting drug users. All data were provided by the Member States with the exception of the injecting drug use prevalence estimate for Malta (which was calculated by the EMCDDA by applying an injecting rate based on treatment data to the existing estimate of the number of problem drug users). The most recent data available show that provision of syringes to drug injectors varies considerably between countries. We calculate that the number of syringes per estimated drug injector per year distributed through needle and syringe programmes is 2 to 3 in Greece, between 60 and 90 in Latvia, Austria, Portugal and the Czech Republic, 110 in Finland, and over 200 in three cases (210 in Malta and more than 250 in Luxembourg and Norway).
Syringes are also available from other sources, in particular from pharmacies, and data on sales of syringes through pharmacies, the Czech Republic and Finland, allow overall syringe availability to be estimated for these two countries. Combining distribution via NSP and pharmacy sales data indicates that drug injectors in the Czech Republic and Finland obtain on average between 125 and 140 syringes per year. This information implies that, even in countries such as these, where needle and syringe programmes are regarded as having good levels of coverage, around 20 % to 30 % of all syringes used by injectors might be coming from pharmacy sales.
This finding indicates that pharmacy sales may play an important role in providing access to sterile injecting equipment. For this reason, in the measurement of syringe distribution it is important to take account of the availability of syringes through pharmacy sales (prices, density of pharmacy network). The measurement of syringe provision to injecting drug users is based on as yet poor data, but together with information on drug injectors’ behavioural patterns and environmental factors it is an important source of data for understanding the likely effects of the distribution of syringes in disease prevention. Syringe provision at pharmacy outlets is currently recorded (see Tables NSP-3 to NSP-6) in this bulletin whenever reported by the countries, and as further data become available a more complete European picture can be developed.
Alongside the general availability of sterile equipment for injectors, other factors influence the blood-borne transmission of infectious diseases among injecting drug users. These factors include the frequency of injecting and the frequency of needle sharing. A recent study in this area suggested that the effect of sterile syringe distribution is largely mediated by the role of safe re-use of an injector’s own syringes and the existence of small, stable injecting groups for sharing (Vickerman et al., 2006). The study's authors suggest that these may be suitable areas for targeted interventions. There are other questions concerning who actually uses the distributed syringes. Injectors who collect, and may re-distribute, injecting equipment are presumed to be (or to be in contact with) heavier users and more frequent injectors, the target group that will probably have most effect on public health levels. There is obvious advantage to including basic audit and monitoring components in needle and syringe programmes in order to gain a better understanding of the level to which these services penetrate through to high-risk drug injectors. Within the important public health goal of preventing the spread by contaminated syringes of blood-borne infections, especially HIV/AIDS, the overall availability of sterile injecting equipment makes an unavoidable contribution and methods of monitoring its impact and adequacy should be developed further.
Eurostat, Monthly labour costs (http://epp.eurostat.ec.europa.eu).
Vickerman, P., Hickman, M., Rhodes, T. and Watts, C. (2006), ‘Model projections on the required coverage of syringe distribution to prevent HIV epidemics among injecting drug users’, Journal of acquired immune deficiency syndromes 42(3): 355-61.