National strategy for prevention of drug addiction until year 2012 2012 annual report

National strategy for prevention of drug addiction until year 2012 2012 annual report Introduction The national strategy for prevention of drug addiction adopted by the Estonian Government on April 22 nd, 2004, including an activity plan, consists of six chapters. The present report reflects an overview of the 2012 activities belonging to the scope of administration of the Ministry of Social Affairs, National Institute for Health Development, Ministry of Justice, Ministry of Education and Research, Tax and Customs Board, Ministry of Internal Affairs and the Police and Border Guard Board. The most important activities of the above mentioned areas in year 2011 were continually enabling of drug addiction treatment in houses of detention, activities connected with decreasing of the offering and availability of drugs and development of the substitution punishment system. The end of 2012 also marked the end of the national strategy for prevention of drug addiction. As of 2013, activities connected with the prevention of drug addiction are included in the Public Health Development Plan 2009-2020. Trends in drug use In 2011, another ESPAD survey was conducted among students aged 15 16. This survey is carried out after every four years and it provides a comparison of changes in the drug use by young people. According to the ESPAD survey on drug use conducted in 2011, it may be said that the increase in drug use among students has slowed down. In 1995, 7% of students had tried some type of narcotic substance, in 1999, 15%, in 2003, 24% and in 2007, 30% of students, but according to the survey of 2011 the percentage has increased by 2. (Allaste et al., 2008; National Institute for Health Development, 2005; RASI, 2012). The proportion of injecting drug users in the 15 44 age group has dropped from 2.7% (1.8% 7.9%) in 2005 to 2% (1.4 5%) in 2008 and to 0.9% (0.7 1.7%) in 2009. In absolute numbers, there were about 5,362 (3906 9837) injecting drug users in 2009 (Uusküla et al., 2012). Prevention Strategic goal 1. The number of cases of first-time users of drugs has started to decrease and the age of first users is showing a tendency of increase. In 2012, prevention activities were implemented by the Ministry of Education and Research (MER), Police and Border Guard Board (PBGB), and the National Institute for Health (NIH) coordinated the activities in the area of administration of the Ministry of Social Affairs. All general education schools and professional schools are involved in drug prevention activities. Teaching life skills is part of the study programme of personal education. In 2012, the national study programme was implemented in the second year of basic school stage, i.e. in year 2, 5 and 8. The final implementation deadline for the study programme was the beginning of the 2013/2014 academic year. Upon preparing the new version of the national study programme, respective health education modules corresponding to certain quality standard requirements were taken into consideration. Personal education remained in the study programme as a separate compulsory subject for all ages. The subject syllabus for personal education takes into consideration the modern trends and treatment of preventing risk behaviour, and prevention activities are integrated in the subject syllabus for personal education for years 2 to 12. The state shall not acquire specific literature for teaching personal education that corresponds to the national study programme. Every year the state allocates funds for local governments to purchase reference books. Acquisition of reference books is carried out on the basis of the individual requirements and opportunities of each school. 1

After completing teacher training, teachers must possess knowledge and skills required for the implementation of national study programme, including the topic of HIV and drug use. Inservice training is offered at all institutions of higher education that specialise in preparing teachers. These are mostly directed at the teachers of personal education. It is not expedient to offer universal in-service training to all teachers on the topic of drug use prevention. Amendments have not been entered into the Juvenile Sanctions Act (JSA) in relation with or on the basis of said strategies. As amendment of the Juvenile Sanctions Act has been initiated, evaluation of current legislation is not expedient. The deadline for the submission of draft to the Government of the Republic shall be autumn 2013. The proportion of young persons who have been referred to the juvenile committee because of the use of a drug or psychotropic substance of all young persons referred to the juvenile committee is very small and most committees do not come into contact with such cases. If in 2007, 4% of all initiated discussions were initiated in juvenile committees pursuant to JSA 1(3)(2), in 2008, the respective figure was 7% and in 2010, 5% of all discussions. Pursuant to the abovementioned provision, young persons who have consumed alcohol, used drugs or psychotropic substances, can be referred to the juvenile committee, which means that given absolute numbers describe the consumption of drugs as well as of alcohol and other substances. Members of juvenile committees receive training simultaneously with the preparation of new legislation. 30 members of juvenile committees completed in-service training in 2012. Basic training of the members of juvenile committees was carried out in three modules from November, 2012, to March, 2013. Several members have also participated in in-service trainings on drug use prevention conducted under a programme of the European Social Fund (ESF). The MER did not plan separate trainings for networking and drug use prevention in 2012. Under the programme Improving the quality of youth work of the European Social Fund (ESF) the Estonian National Agency for Youth in Action carried out 43 training activities in 2012 with about 1034 young persons and youth workers as participants. Among other things, training was conducted for working with specific target groups and improving special knowledge and skills, incl. prevention of drug use (528 specialists participated). Information on drug prevention is distributed to young people through information and counselling centres operating in all counties and larger towns. Centres provide visual information on the effects of addictive substances (incl. tobacco and alcohol), primary selfdefence equipment and information on counsellors who to contact for help. 19 information and counselling centres for young people operated in Estonia in 2012. Upon providing information to young people it is important to assess the expected effect of informing activities and whether it fulfils set goals. This is necessary so as to prevent the distribution of information from becoming an activity of fostering drug use. Since 2007, a separate trend in informing young people of the risks accompanying drug use has been training for the young people by young people which are funded from the resources of the national HIV/AIDS prevention strategy. In 2012 an agreement was concluded with three partners for the preparation of persons carrying out training for the young people by young people: Social Centre of Central Estonia, Anti-AIDS Association and Living for Tomorrow. The total number of new young training providers prepared by these associations was 233. Continuous training was offered to 14 young persons who had previously completed this training. Unfortunately, young training providers have not established a network. A significant innovation was included in the preparation of the training plan for the new period that began in autumn. Trainings were directed to a more specific and smaller target group. Special attention was paid to young people studying at vocational schools and schools for students with special needs as well as to the personnel of said schools and areas that lie further away from major centres. 2

In the schools for students with special needs prevention activities regarding drug use are carried out in the course of providing general schooling and educational activities. Drug use prevention programmes are not conducted outside school activities; it is included in the provision of schooling and educational activities. Topics are addressed as part of the study programme in personal education classes. Prevention activities include all students of specialized schools (80 students in 2012). In 2012, the NIH carried out four trainings in specialized schools that included both HIV and drug prevention. One student of specialized school participated in the support group for drug addicts. The NIH helped to improve the efficiency of prevention activities at national and local level through the training of specialists dealing with young people, provision of information on drugs at events and via youth portals, financing of projects initiated by young people and financing the counselling service aimed and young people and parents. As a new activity, preparation of the document Drug policy at school: advice for the development of drug policy at school started in 2012. The purpose of this manual is to help schools develop a drug policy that would correspond to their needs, which would affect the social environment of the school, determining limits for permitted and prohibited behaviour and measures to be taken when said limits are ignored. Prepared material can be used in primary schools, basic schools and upper secondary schools as well as in public schools, private schools and specialised schools. In 2012, trainings based on the instruction material Räägime tervisest ( Let s Talk about Health ) were carried out in various towns in Estonia for specialists working with young people. Instruction material Räägime tervisest consists of six chapters, with each chapter including a theoretical part and a selection of active tasks. The website www.narko.ee, aimed at the general public, was updated in the second half of 2012. New texts in Estonian were written and edited for the website and the website s layout was updated. Answers were provided to questions submitted through the website. The updated website was made public in the 1 st quarter of 2013. From year 2004, the NIH has financed a project competition of young people called TEIP (project of health-promoting ideas). In 2012, six winning projects of the previous year were implemented, and in the autumn a new competition round was carried out where a total of 84 project ideas were received. The jury selected six projects out of the ones submitted, to be implemented in 2013. The projects having won in 2011 and implemented in 2012 included a total of 3,531 participants. As in previous years, the NIH participated in youth exhibition called Teeviit. At the exhibition that lasted three days, information was provided on various health topics. 1,281 DVDs with a drug prevention training film called "Mõtteaine" ( Food for Thought ) were distributed to basic schools, upper secondary schools, vocational schools and youth centres. Information material accompanying the training film was distributed 33,636 copies in Estonian and 4,928 in Russian, and the instruction manuals aimed at teachers were distributed 1,253 copies in Estonian and 270 in Russian. The PBGB contributed to prevention activities by supporting drug prevention projects which reached over 10,000 minors in 2012. Therapy Strategic goal 1. By year 2012, a modern, professional and available high-level network of health and social aid services for providing effective help to drug addicts, both children and adults, shall be developed (there are therapy and rehabilitation 3

centres with various patterns of operation for children and adults with addiction and personality disorders of various levels of difficulty). Within the national HIV and AIDS strategy, 679 places for Methadone substitution therapy were financed in 2012; 687 people were receiving therapy as of the end of the year. Throughout the year, 1,157 persons received the service. 2012 saw the addition of a new provider of Methadone substitution therapy - Tartu University Hospital - which improved the regional availability of the service. Within the national strategy for prevention of drug addiction, 26 24-hour rehabilitation places were financed for male addicts (Sillamäe Rehabilitation Centre). As of April, 2012, 24-hour rehabilitation service is provided to female addicts in the Psychiatric Clinic of Viljandi Hospital (10 places). The rehabilitation team of Viljandi Hospital consists of specialists of various fields: psychiatrist, psychologist, social worker, nurse, physiotherapist, occupational therapist and activity leaders. The centre is located in the territory of Jämejala Psychiatric Clinic of Viljandi Hospital. As of 2013, Viljandi Hospital also provides rehabilitation services to male patients (10 places). With funds from the ESF programme, out-patient counselling service was provided to persons with addiction problems in various locations across Estonia (Ida- and Lääne- Virumaa, Harjumaa, Tartumaa). Counselling service to persons with addiction problems and persons they are close to have been provided since autumn 2010 with funds from the ESF programme. In 2012, 891 persons received social counselling, peer counselling and psychological counselling as well as psychotherapy. Financing of short-term in-patient aversion therapy service, launched in 2011, was continued. To establish the results achieved during the short-term aversion therapy, patients can continue to receive out-patient follow-up counselling service for up to 3 months. Follow-up counselling consists of a weekly visit to a psychologist and a psychiatrist s consultation every other week. Even though demand for short-term aversion therapy remains stable, premature interruption of therapy poses a serious problem, indicating that the activities and content of the service need reviewing and should better correspond to patients needs. Another serious problem is the complete lack of in-patient aversion therapy in the area of Ida-Virumaa. For drug addiction therapy of minors, there are a total number of 6 places in Estonia (2 by the children s department of the psychiatric clinic of Tartu University Hospital and 4 in Tallinn Children s Hospital). For the fourth year in a row, psychological, schooling and education activities of children and young people with addiction disorders in Tallinn Children s Hospital was financed within the national strategy of prevention of drug addiction. A training visit took place in February, 2012 to the therapy and rehabilitation centres belonging to the Bergen Clinics Foundation in Norway. It was a preparatory activity to launch a new rehabilitation service on the basis of Viljandi Hospital. Bergen Clinics Foundation has a long-term experience in working with addicts, both adults and minors, male and female addicts. By now, consistent cooperation has developed with Bergen Clinics Foundation. In November, Kari Lossius, head of the clinic and clinical psychologist, carried out a training session in Estonia on the topic of women and addiction, and a day-and-a-half-long inversion for the rehabilitation team of Viljandi Hospital. Clinical protocol of opioid addiction substitution therapy was completed; the original project of said protocol had been prepared in 2011. In 2012, this protocol was reviewed with relevant associations and many discussions were held with service providers. In 2012, OÜ Corrigo continued to provide counselling to young people and parents, and Tallinn Children s Hospital organised psychotherapy groups for parents and minors. In 4

addition to individual psychological counselling, OÜ Corrigo carried out interactive trainings in educational institutions. Harm reduction Strategic goal 1. Decreased risk behaviour among drug addicts. Activities connected with the injection of drugs, syringe exchange and Methadone substitution therapy are discussed in the national HIV and AIDS strategy report of year 2012. On 27-28 January, 2012, a seminar took place on the prevention of death and overdoses, conducted by experts from the Eurasian Harm Reduction Network (EHRN) and Scotland. The goal of the seminar was to provide an overview of various models of preventing overdoses to organisations providing the services of harm reduction and therapy in Estonia, and introduce the experience of various countries; also, it was discussed which model for prevention of overdoses would be suitable for Estonia. At the end of 2012, a draft description and plan of action were completed for the programme Use of Naloxone to prevent death by overdose. Pilot project on this topic shall be launched in 2013. Drugs in prison Strategic goal 1. A control system is functioning to prevent access of drugs to prisons. In-prison therapy and rehabilitation services have been ensured for addicts. The Ministry of Justice and its subdivisions are responsible for the implementation of activities connected with drugs in prison. To discover drugs, searches were conducted 6 times in 2012 by the armed unit of prisons. This is less than prescribed in the plan of action and is due to the fact that the number of both prisons and prisoners has decreased. The prisoners were tested for drug use more than prescribed in the plan of action: instead of the scheduled 2,000 tests, 3,508 tests were performed in 2012. The prison service has created departments of addiction rehabilitation in prisons for resocialising addicts. There is a result centre in Tartu with 174 places, which is divided into four sections. The main active rehabilitation takes place in the third section (44 places). In 2010, also a fourth, so-called post-rehabilitation department was created with also 44 places, where the prisoners having passed active rehabilitation phase are located. Also, addiction rehabilitation departments are in Viru Prison (20 places for young people and 20 for adults) and in Harku Prison (8 places). The remaining rehabilitation of addicts takes place under social programmes. In prisons, therapy is provided to addicts with non-opiate medicines but Methadone therapy can also be provided. Methadone aversion therapy was provided 61 times and Methadone substitution therapy was provided to 50 prisoners in the 1 st quarter of 2012, 45 prisoners in the 2 nd quarter, 69 prisoners in the 3 rd quarter and 62 prisoners in the 4 th quarter of 2012. For comparison in 2008, aversion therapy with substitution medicine was carried out only on 2 occasions (plan was 100), and in 2009 on 12 occasions (plan was 20). With the help of the Ministry of Justice, Methadone therapy is also ensured in Viru detention house in order not to interrupt the treatment started in freedom. In years 2007 2012 trainings in several areas have been repeatedly organised for prison officers: basic training on drugs, methods of motivating counselling, opiate addiction therapy. Also, additional trainings have been organised for guards dog handlers. 5

In 2012, 20 officials were trained to implement in the prison system the social programme Lifestyle training for offenders, aimed at the abusers/addicts of substances for whom such addiction leads to unlawful behaviour. Trainings on motivational interviewing are also organised every year. This is a basic skill that is trained every year as necessary. Eight trainings were organised in 2012 with 85 officials participating. 20 officials were provided three trainings under the programme The Right Moment. This is an individual programme which aims to help the convicted person acquire, develop and apply skills related to resolving social problems to cope with problematic situations. There are 11 sniffer dogs and 11 dog-handlers in prisons. In 2012, a training session for new sniffer dogs and dog-handlers was organised, and 7 dog-handlers received in-service training. 8 ministers of religion for prisons were trained in 2012, and also 12 religious volunteers and theology students participated in the training. Supply reduction Strategic goal 1. The availability of narcotic substances is decreasing and the criminal proceeds are confiscated, training and equipment are modern and conforming to the requirements. The efficiency of activities is governed by supplemented legislation. The Ministry of Internal Affairs, the Police and Border Guard Board (PBGB) and the Tax and Customs Board (TCB) are responsible for implementing activities connected with supply reduction. For many years, the activities of the police in combating drugs focused on the reduction of organised crime. As of 2012, however, the activities connected with supply reduction also include activities clearly protecting public health. Confiscation of Fentanyl, a narcotic substance that is the cause of most drug-related deaths, became important, and additional resources were allocated for the police for catching street dealers. In 2012, a total of 1.7 kilograms of Fentanyl was discovered; this equals several thousand doses that could have been sold. In 2012, Fentanyl was one of the main causes of drug-related deaths as it is a strong narcotic substance which is very easy to overdose. Thus, Fentanyl shall remain a priority among narcotic substances in the near future, and its spreading shall have to be restricted. Within the past ten years, over 1,000 persons have died in Estonia as a result of using drugs, including 160 persons in 2012. Confiscated illegal drugs in 2011 and 2012 (kg) Substance 2011 2012 Fentanyls 1.0 1.7 Amphetamine 41.3 13.4 Metamphetamine 1.5 26.8 Cocaine 0.8 3.4 Cannabis 29.3 6.6 Marihuana 53.5 25.0 GHB 13.5 28.4 GBL 2.3 197.2 In comparison to 2011, the number of drug crimes has decreased. If in 2011, the number of drug crimes was 804, the respective number in 2012 was 794. Drug crimes formed 2% of all registered crime. 6

Successful cooperation operations were carried out with various institutions in 2012. A total of 69 national and 10 international joint operations took place. To increase the capacity for detecting criminal proceeds, an office for detecting criminal proceeds was established on September 1 st, 2011, which is a structural unit of the PBGB. The office is responsible for the whole area of detection of criminal proceeds in the PBGB. Officials detecting criminal proceeds have also been appointed in all four regional offices of the TCB. A total of 1.5 million euros worth of criminal proceedings were confiscated, which exceeds the amount of 2011 by nearly a half. In 2012, the TCB discovered a total of 51,063.55 grams of narcotic substances. If the types of narcotic substances trafficked across the border have generally remained the same, changes have taken place in the methods of trafficking drugs and their source substances in comparison to the earlier period. During the period in question, drug traffickers started to bring drugs across the so-called green border, and instead of small vehicles traffickers now prefer coaches and trucks as these have more hidden compartments and that are generally checked less often. For the detection of drugs, the TCB uses 19 sniffer dogs. In 2012, there were 698 calls for sniffer dogs, with a total of 71 detections. Every year, an evaluation of Estonian crime situation is prepared by the Police and Border Guard Board in cooperation with the Tax and Customs Board. Based on the above document, the common subjects of procedural interest for the TCB and the PBGB (including person s connected with drug crimes) are mapped out and future directions for procedures are agreed. Surveillance, quality management, evaluation and scientific research Strategic goal 1. Implementation of surveillance, evaluation and quality management of the field of drugs in order to ensure policy introduction. Implementation of activities connected with surveillance and evaluation are the responsibility of Eesti Uimastiseire Keskus (Estonian centre for drug surveillance EUSK) 1, operating at the National Institute for Health, the main task of which in 2012 was fulfilment of the grant agreement of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), a decentralised agency of the European Union. The content of the grant agreement concluded between EMCDDA and the NIH was participation in the implementation of the work programme of EMCDDA for year 2012 as a national drug information centre as a REITOX network drug surveillance centre. Relying on the information of year 2011, in 2012 a report was created about the situation of drug addiction, preventive activities and the development of the drug policy in Estonia. The report is available in Estonian and English in the web page of the NIH (http://www.tai.ee). In 2012, maintenance of the drug addiction therapy database continued. The database of drug addiction therapy is a state register providing an overview of persons having registered for drug addiction therapy. In cooperation with the Ministry of Social Affairs, preparations were made for the individualisation of the drug addiction therapy database. In the 2 nd quarter of 2013, the annual report of the drug addiction therapy database shall be compiled on the basis of 2012 data. In the area of exploring and evaluating the health situation and factors influencing the health of the people, a survey Number and prevalence of population group of injecting drug users among the population was completed in cooperation with the Department of Public Health of the University of Tartu. Findings of the survey were published with prior review in a scientific 1 As of 2013, Infectious Diseases and Drug Monitoring Centre 7

journal International Journal of Drug Policy (summary of the article is available here: http://www.ncbi.nlm.nih.gov/pubmed/23290632). In cooperation with the Department of Public Health of the University of Tartu a survey called Factors affecting HIV prevalence and availability of services among injecting drug addicts living in Russia and Estonia was carried out, in the course of which the factors affecting tuberculosis and availability of services in Estonia were surveyed. Estonian survey was part of an international survey conducted under TUBIDU project. The survey was financed from the budgets of TUBIDU project of the NIH and the Department of Public Health of the University of Tartu. 3 meetings of the government committee on drug prevention took place in 2012. A meeting on the topic of therapy, another on prevention and the third on supply reduction. Committee members include the Minister of Internal Affairs, Minister of Education and Research, Minister of Justice and the Minister of Social Affairs as well as heads of relevant agencies, experts and representatives of local governments and third sector. Members of the committee meet regularly so as to link the activities of different ministries and partners and coordinate activities for future periods. Such cooperation ensures that the activity of combating drugs is not random but deliberate and under constant surveillance. Financing The total amount of expenses of the national strategy of prevention of drug addiction until 2012 was 2,322,755.43 euros. Execution of budget by agencies Budget (EUR) Execution (EUR) Ministry of Social Affairs 1,386,852 1,342,814 incl. NIH 1,385,852.00 1,341,478.73 incl. Department of Children and Families 1,000.00 1,335.00 incl. Ministry of Social Affairs 0.00 0.00 Ministry of Education and Research 332,147.00 332,147.00 Ministry of Internal Affairs 512,178.57 460,646.70 incl. Police and Border Guard Board 512,178.57 460,646.70 incl. Ministry of Internal Affairs 0.00 0.00 Tax and Customs Board 277,550.00 163,450.00 Ministry of Justice 12,700.00 23,698.00 TOTAL 2,521,427.57 2,322,755.43 Unfortunately, it is not possible to list all used resources among actual costs as the topics related to drug use often form a part of a larger activity or part of the institutions general operational expenditure. In addition to the state budget, ESF funds were used for financing the activities of drug strategy in 2012. Activities focused on the development and provision of counselling services aimed at persons with addiction disorders. ESF funds were used in a total of 213,412.55 euros. Priorities for 2013 Implementation of the clinical protocol of opioid addiction substitution therapy. Supplementation of the instruction manual for in-patient rehabilitation service. 8

Participation in the cooperation project of the Ministry of Justice and Switzerland (preparation of the development of evaluation instruments for persons with addiction problems and preparation of training). Implementation of the pilot project on preventing overdoses of Naloxone. Integration of out-patient counselling services and follow-up services in other services so as to ensure their sustainability once the ESF financing ends. Participation of the NIH s centre for drug surveillance as a REITOX network drug surveillance centre in the implementation of the work programme of EMCDDA for year 2013 on the basis of the grant agreement concluded between EMCDDA and the NIH. Maintenance and individualisation of the drug addiction therapy database. Detection and restriction of drug use in prisons. Implementation of drug therapy as an alternative punishment. Provision of substitution and aversion therapy as well as rehabilitation services in prisons. Improving the direction of joint activities and contributing to the discovery of manufacturers and sellers of Fentanyl and Amphetamine. Development and implementation of national early warning system of narcotic substances. Focusing on international drug crime, discovery of couriers and operative cooperation at both national and international level. Preventing the spreading of Fentanyl. 9