ImPact of coVID-19 on DruG marketS, uSe, harmS anD DruG SerVIceS In euroPe

Since early 2020, the COVID-19 pandemic has had a dramatic impact on the way we live, with European countries having to introduce unprecedented measures to protect public health. As with all areas of life, drug consumption, related harms and drug markets have been impacted, as have the drug services established to respond to drug-related problems. Since the start of the pandemic in March 2020, the European Monitoring Centre for Drugs and Drug Addiction instigated three rapid assessment studies to identify the initial impact and implications of COVID-19 on drug markets, use, harms and drug services in the community and in prisons. Findings from these studies revealed that the pandemic and associated health prevention measures by the countries impacted drug markets and use differently depending on the different periods and events throughout the pandemic, but also according to particular drugs or user characteristics. Most drug services remained operational throughout the pandemic in order to assure continuity of care. This was achieved by innovation and adaptation of their services, especially during the different lockdown periods. Thus, the results from these rapid assessments provide a glimpse into new developments in the drugs field across European countries emerging both during and in response to the pandemic, and which could have important implications for the future.


Background
On 11 March 2020, the World Health Organization declared COVID-19 a pandemic. Since then, the virus has claimed millions of lives and has transformed nearly every aspect of our individual and collective reality. As with all areas of life, drug consumption, related harms and drug markets have been impacted, as have the services established to respond to drugrelated problems. As we enter third year of the pandemic, a number of observations in these areas can be drawn from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) studies that were carried since the start of the pandemic to assess the impact and implications of COVID-19 on the drug situation in Europe.
During the first weeks of the pandemic in 2020, the EMCDDA instigated two rapid assessment studies, followed by a third rapid assessment in 2021 on the impact of COVID-19 and related national prevention responses on drug markets, use, harms and drug services in Europe (EMCDDA, 2020a(EMCDDA, , 2020b(EMCDDA, , 2021a. These rapid assessments, called EMCDDA Trendspotter studies, triangulate data from key informants, national focal points, online surveys of people who drugs, city-based wastewater analysis, and emerging data from established and developmental indicators (such as drug checking, syringe residue analyses, hospital emergencies, etc). While the lack of comprehensive data during that period due to partial disruptions in data collection or monitoring activities means that all conclusions must be made with caution, the results of these studies still provide a preliminary insight on the impact of the pandemic on the drug situation in Europe. For detailed information on the methods of the EMCDDA Trendspotter studies, please see EMCDDA 2018 and 2021a.

findings
One of the main findings from the EMCDDA studies is that the drug market has been remarkably resilient to disruption caused by the pandemic. Drug traffickers adapted to travel restrictions and border closures. At wholesale level this was reflected in some changes in routes and methods, with more reliance on smuggling via intermodal containers and commercial supply chains and less reliance on the use of human couriers. Thus, more cannabis and heroin smuggled by sea, to avoid land border closures, leading to large seizures in Europe's ports. Some changes were observed in the departure locations of cocaine trafficked from Latin America to Europe. However, no decline in supply was evident, and multi-tonne seizures of cocaine were reported in European ports in 2020 and early 2021, including 16 tonnes in Hamburg in Germany and 7.2 tonnes in Antwerp in Belgium (EMCDDA, 2021b;EMCDDA and Europol, 2020). Reports indicated that cannabis cultivation and synthetic drug production within the European Union continued at pre-pandemic levels during 2020. While street-based retail drug markets were disrupted during the initial lockdowns, and some localised shortages were experienced, drug sellers and buyers appeared to have adapted by increasing their use of encrypted messaging services, social media applications, online sources and mail and home delivery services. This raises the concern that a possible long-term impact of the pandemic will possibly be further digitally enabled drug markets.
Findings from the EMCDDA rapid assessments also suggests that any reductions in drug consumption seen during the initial lockdowns in the Member States in the first half of 2020, rapidly disappeared as social distancing measures were eased. In general terms, there appears to have been less consumer interest in drugs usually associated with recreational events, such as MDMA, and greater interest in drugs linked with home use. However, the easing of restrictions on movement and travel and a return of social gatherings from the summer 2020 onwards was associated with a rebound in the levels of use. Available data from the analysis of wastewater samples in European cities indicate that levels of use of most drugs appeared generally lower during the initial lockdowns in 2020, but then appeared to bounce back once lockdown were lifted. A comparison with 2019 suggests similar overall consumption of most drugs and in several cities possibly even higher levels, based on this data source. Exceptions here appear to be MDMA and methamphetamine, two drugs for which the levels observed in 2020 appeared lower in most of the participating cities. Less consumer interest in MDMA during the pandemic is supported by user reports collected through the EMCDDA web survey on drugs, where a decline in use was noted, and some limited data on hospital emergencies, which showed a decline in MDMArelated admissions. This is against a background of high availability of this drug, as indicated by the continued detection of high-strength MDMA tablets in most countries by European law enforcement and drug checking services. Interestingly, Dutch drug monitoring services reported the introduction of lower-strength tablets, apparently marketed as more suitable for home use.
EMCDDA web survey data from people who selfreport drug use also pointed to higher consumption of alcohol and greater experimentation with psychedelics, such as LSD and 2-CB (2,5-dimethoxy-4-bromophenethylamine), and dissociative drugs such as ketamine. This may reflect a growth in demand for substances possibly perceived as more suitable for home consumption. The same web-survey also found that those using drugs occasionally prior to COVID-19 may have reduced or even ceased their use during the pandemic, but more regular and frequent users may have increased their drug consumption. This could have important implications for prevention and treatment services if the changes observed are substantiated and persist into the future.
Furthermore, an increase in reports of cannabis adulterated with synthetic cannabinoids emerged in several European countries during 2020 and continued in 2021. It is not known what could be driving this development but it could possibly reflect both shortages of cannabis linked to the pandemic or, possibly, criminal groups exploiting the availability of low-THC cannabis products in some countries, which may be difficult to distinguish from cannabis sold on the drug market. Any scenario where people unwittingly consume synthetic cannabinoids is worrying given the toxicity of some of these substances, as illustrated by an outbreak of over 20 deaths related to the synthetic cannabinoid 4F-MDMB-BICA in 2020.
Among the possible worrying developments associated with the pandemic is the observation that some countries are seeing an increase in crack cocaine availability and use. Also of concern were reports of increased availability of smaller doses or cheaper packages of heroin, crack and benzodiazepines targeting problem drug users with financial difficulties during the pandemic. Drug problems are often found in marginalised groups such as the homeless, and those with drug problems may often rely on informal or parallel economies. It is likely these groups have been financially disadvantaged and reduced income by social distancing measures, travel restrictions and lockdown measures, and may be particularly vulnerable to any future economic difficulties resulting from the ongoing health crisis.
Growing concerns were also noted about the misuse of benzodiazepines, either diverted from therapeutic use or benzodiazepines not licenced for medical use in Europe appearing on the illicit drug market. Increased use of benzodiazepines was seen among high-risk drug users, prisoners and some groups of recreational drug users, potentially reflecting the high availability and low cost of these substances and pandemic-related mental health issues. A sample of European sentinel hospitals observed an increase in emergency presentations related to benzodiazepines in 2020 compared with 2019.
Findings from the initial EMCDDA rapid assessments carried out in March and April 2020 (EMCD-DA, 2020a) suggested a decline in the availability of European drug services during the first two months of the pandemic, with an associated decline in both new treatment entrants and all other treatment entrants, while harm reduction services remained a key frontline actor during and after the first lockdowns. A greater use of telemedicine by drug professionals may have contributed to the reduction in reported treatment demand but also allowed services to continue to meet their clients' needs during the pandemic. With nearly 700 000 people receiving opioid agonist treatment (OAT) in Europe annually, service providers and national authorities had to act rapidly and change the way that OAT was provided, both to ensure access to medications for those already in treatment and to respond to new treatment demands.
Drug services across Europe had resumed their operations by June 2020, with a return to face-toface consultations within most drug services by early 2021, although at reduced capacity due to COVID-19 prevention measures. In general, European professionals reported that the COVID-19 prevention measures pushed services to re-evaluate longestablished working procedures. In some cases, this resulted in increased efficiency and innovation in service provision.
Treatment services in prison settings also reported service disruptions due to social distancing and restrictions on external service providers. Restrictions on access by external visitors and contractors to prisons also are also reported to have temporarily reduced the availability of drugs in some prisons.

conclusion
In conclusion, findings from the EMCDDA rapid assessments point on the impact of the pandemic to a number of new developments and trends that warrant further research and close monitoring. In the future there will be a need to pay close attention to the psychological and socioeconomic impacts of the pandemic, as well as longer term changes in patterns of illicit drug use and risk behaviours among the wider population. Furthermore, the shift to the greater use of online platforms both for drug supply at the retail level, but also for the clinical management of drug problems will undoubtedly persist beyond the pandemic. Finally, these findings provide a valuable first glimpse into the new developments emerging from the pandemic, one which could have important implications for the future as we (hopefully) move into a post-COVID-19 period.