Influent wastewater analysis to investigate emerging trends of new psychoactive substances use in Europe.

Wastewater-based epidemiology (WBE) can provide objective and timely information on the use of new psychoactive substances (NPS), originally designed as legal alternatives of internationally controlled drugs. NPS have rapidly emerged on the global drug market, posing a challenge to drug policy and constituting a risk to public health. In this study, a WBE approach was applied to monitor the use of more than 300 NPS, together with fentanyl and its main metabolite norfentanyl, in influent wastewater collected from 12 European cities during March-June 2021. Quantitative and qualitative analysis of NPS in composite 24 h influent wastewater samples were based on solid phase extraction and liquid chromatography-mass spectrometry. In-sample stability tests demonstrated the suitability of most investigated biomarkers, except for a few synthetic opioids, synthetic cannabinoids and phenetylamines. Fentanyl, norfentanyl and eight NPS were quantified in influent wastewater and at least three substances were found in each city, demonstrating their use in Europe. N,N-dimethyltryptamine and 3-methylmethcathinone (3-MMC) were the most common NPS found, with the latter having the highest mass loads (up to 24.8 mg/day/1000 inhabitants). Seven additional substances, belonging to five categories of NPS, were identified in different cities. Spatial trends of NPS use were observed between cities and countries, and a changing weekly profile of use was observed for 3-MMC. WBE is a useful tool to rapidly evaluate emerging trends of NPS use, complementing common indicators (i.e. population surveys, seizures) and helping to establish measures for public health protection.

Framing substance use as "recreational" is neither accurate nor helpful for prevention purposes.

This debate paper discusses six reasons why the term "recreational substance use" should be avoided. (1) Social norms and beliefs are drivers of behavior; therefore, the normalized use of the term conveys injunctive norms of a fully socially acceptable substance. Injunctive norms are the most important drivers of initiation into substance use. (2) The illusion of being in control, suggesting that if consumed for leisure and recreation it can easily be controlled; (3) Idealized social representations that fuel an idealized image of an alternative glamourous or mindful consumption culture; (4) Downplaying potential harms; (5) The implicit promise of everyday pleasure, the ever-growing potency of cannabis products does not fit the narrative of its use for recreation; (6) Industry as a trojan horse branding discourse of the concept of medical cannabis to normalize the image of non-medical use: to complement "therapeutic" with "recreational". "Recreational use" is a subjective ill-defined term. This debate paper aims to find a better terminological solution, honestly denominating with a neutral, unbiased, and objective connotation what is now called "recreational use". Thus, we propose using the term "non-therapeutic" use.

Spatial and temporal assessment of crack cocaine use in 13 European cities through wastewater-based epidemiology.

Already in early 2000s, concerns have been growing in the EU about increasing use of cocaine and it is estimated that below 1 % of the population administer the drug by smoking crack cocaine. New available data suggests an increase in the use of crack cocaine and an increase in the number of crack cocaine users entering treatment has been reported in several European countries. Robust estimations of crack cocaine use are however not available yet. The use of crack cocaine has long been associated with severe adverse socio-economic conditions as well as mental health problems, such as suicide ideation and depression. The aim of this study was to assess spatial trends in population-normalized mass loads of crack cocaine biomarkers (i.e., anhydroecgonine and anhydroecgonine methyl ester) in 13 European cities in six countries (the Netherlands, Belgium, Ireland, Portugal, Spain and Italy). Furthermore, temporal trends over a five-year period were evaluated through the analysis of historic samples collected in the Netherlands. Finally, the stability of the crack cocaine biomarkers in wastewater was investigated through batch experiments. The samples were analyzed with a new developed and validated hydrophilic interaction liquid chromatography coupled to mass spectrometry method. Targeted crack cocaine biomarkers were found in all cities. Also, crack cocaine biomarker was detected in wastewater from 2017 to 2021 in the Netherlands, but no significance between the years were found. With respect to biomarker in-sample stability, AEME was found to be stable in wastewater. This study assessed crack cocaine use for the first time on a broad scale, both temporal and in cities across Europe, with wastewater-based epidemiology and it shows the importance of wastewater analysis to monitor community loads of crack cocaine use.

Use of illicit drugs, alcohol and tobacco in Spain and Portugal during the COVID-19 crisis in 2020 as measured by wastewater-based epidemiology.

The COVID-19 pandemic spread rapidly worldwide in the year 2020, which was initially restrained by drastic mobility restrictions. In this work, we investigated the use of illicit drugs (amphetamine, methamphetamine, ecstasy, cocaine and cannabis), and licit substances of abuse (alcohol and tobacco) during the earlier months (March-July 2020) of the pandemic restrictions in four Spanish (Bilbao and its metropolitan area, Vitoria-Gasteiz, Castellón and Santiago de Compostela) and two Portuguese (Porto and Vila do Conde) locations by wastewater-based epidemiology (WBE). The results show that no methamphetamine was detected in any of the locations monitored, while amphetamine use was only detectable in the two locations from the Basque Country (Bilbao and its metropolitan area and Vitoria-Gasteiz), with high estimated average usage rates (700-930 mg day-1 1000 inhabitant-1). The remaining substances were detected in all the investigated catchment areas. In general, no remarkable changes were found in population normalized loads compared to former years, except for cocaine (i.e. its main metabolite, benzoylecgonine). For this drug, a notable decrease in use was discernible in Castellón, while its usage in Porto and Santiago de Compostela seemed to continue in a rising trend, already initiated in former years. Furthermore, two events of ecstasy (3,4-methylenedioxymethamphetamine, MDMA) dumping in the sewage network were confirmed by enantiomeric analysis, one in Santiago de Compostela just prior the lockdown and the second one in the Bilbao and its metropolitan area in July after relieving the more stringent measures. The latter could also be associated with a police intervention. The comparison of WBE with (web) survey data, which do not provide information at a local level, points towards contradictory conclusions for some of the substances, thereby highlighting the need for stable WBE networks capable of near real-time monitoring drug use.

The impact of the COVID-19 lockdown on drug service provision in European prisons.

PURPOSE: This paper aims to describe the impact of the COVID-19 containment measures on the provision of drug treatment and harm reduction services in European prisons in15 countries during the early phase of the pandemic (March -June 2020). DESIGN/METHODOLOGY/APPROACH: The paper is based on a mixed method research approach that triangulates different data sources, including the results of an on-line survey, the outcome of a focus group and four national case studies. FINDINGS: The emergence of COVID-19 led to a disruption in prison drug markets and resulted in a number of challenges for the drug services provision inside prison. Challenges for health services included the need to maintain the provision of drug-related interventions inside prison, while introducing a range of COVID-19 containment measures. To reduce contacts between people, many countries introduced measures for early release, resulted in around a 10% reduction of the prison population in Europe. Concerns were expressed around reduction of drug-related interventions, including group activities, services by external agencies, interventions in preparation for release and continuity of care. PRACTICAL IMPLICATIONS: Innovations aimed at improving drug service provision included telemedicine, better partnership between security and health staff and an approach to drug treatment more individualised. Future developments must be closely monitored. ORIGINALITY/VALUE: The paper provides a unique and timely overview of the main issues, challenges and initial adaptations implemented for drug services in European prisons in response to the COVID-19 pandemic.

Supporting Future Cannabis Policy - Developing a Standard Joint Unit: A Brief Back-Casting Exercise.

The standardization of cannabis doses is a priority for research, policy-making, clinical and harm-reduction interventions and consumer security. Scientists have called for standard units of dosing for cannabis, similar to those used for alcohol. A Standard Joint Unit (SJU) would facilitate preventive and intervention models in ways similar to the Standard Drink (SD). Learning from the SD experiences allows researchers to tackle emerging barriers to the SJU by applying modern forecasting methods. During a workshop at the Lisbon Addictions Conference 2019, a back-casting foresight method was used to address challenges and achieve consensus in developing an SJU. Thirty-two professionals from 13 countries and 10 disciplines participated. Descriptive analysis of the workshop was carried out by the organizers and shared with the participants in order to suggest amendments. Several characteristics of the SJU were defined: (1) core values: easy-to use, universal, focused on THC, accurate, and accessible; (2) key challenges: sudden changes in patterns of use, heterogeneity of cannabis compounds as well as in administration routes, variations over time in THC concentrations, and of laws that regulate the legal status of recreational and medical cannabis use); and (3) facilitators: previous experience with standardized measurements, funding opportunities, multi-stakeholder support, high prevalence of cannabis users, and widespread changes in legislation. Participants also identified three initial steps for the implementation of a SJU by 2030: (1) Building a task-force to develop a consensus-based SJU; (2) Expanded available national-level data; (3) Linking SJU consumption to the concept of "risky use," based on evidence of harms.

Changes in drug use in European cities during early COVID-19 lockdowns - A snapshot from wastewater analysis.

The COVID-19 outbreak has forced countries to introduce severe restrictive measures to contain its spread. In particular, physical distancing and restriction of movement have had important consequences on human behaviour and potentially also on illicit drug use and supply. These changes can be associated with additional risks for users, in particular due to reduced access to prevention and harm reduction activities. Furthermore, there have been limitations in the amount of data about drug use which can be collected due to restrictions. To goal of this study was to obtain information about potential changes in illicit drug use impacted by COVID-19 restrictions. Wastewater samples were collected in seven cities in the Netherlands, Belgium, Spain and Italy at the beginning of lockdowns (March-May 2020). Using previously established and validated methods, levels of amphetamine (AMP), methamphetamine (METH), MDMA, benzoylecgonine (BE, the main metabolite of cocaine) and 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THC-COOH, main metabolite of tetrahydrocannabinol (THC)) were measured and compared with findings from previous years. Important differences in levels of consumed drugs were observed across the considered countries. Whilst for some substances and locations, marked decreases in consumption could be observed (e.g., 50% decrease in MDMA levels compared to previous years). In some cases, similar or even higher levels compared to previous years could be found. Changes in weekly patterns were also observed, however these were not clearly defined for all locations and/or substances. Findings confirm that the current situation is highly heterogeneous and that it remains very difficult to explain and/or predict the effect that the present pandemic has on illicit drug use and availability. However, given the current difficulty in obtaining data due to restrictions, wastewater analysis can provide relevant information about the situation at the local level, which would be hard to obtain otherwise.

"Tell Me How Much Your Friends Consume"-Personal, Behavioral, Social, and Attitudinal Factors Associated with Alcohol and Cannabis Use among European School Students.

BACKGROUND: Substance use in European adolescents remains a serious health concern. Assessing what affects adolescents' substance use is crucial for implementing effective prevention. This study aims to examine alcohol and cannabis use-related behavioral, social, and attitudinal variables that might directly be considered to guide prevention responses for adolescents. METHODS: Cross-sectional data of 78,554 15-16-year-old school students from the 2011 European School Survey Project on Alcohol and Other Drugs (ESPAD) from 26 European countries were analyzed. Self-reported drunkenness in the last 30 days and cannabis use in the last 12 months served as dependent variables. To investigate which factors are associated with risky substance use, multivariable logistic regressions were used. RESULTS: 17.7% of respondents reported drunkenness in the last 30 days, and 14.9% used cannabis in the last 12 months. The most important predictor for risky substance use was the perception that most/all of their friends engaged in substance use behavior, followed by lack of parental support, low personal adherence to rules, and low school performance. CONCLUSION: Interventions addressing the perceived descriptive norms either directly or by changing environmental cues, opportunities, and regulations, as well as effective parenting and academic support may prevent and reduce risky substance use behavior among adolescents.

Sources of drug acquisition among females and males in the European Web Survey on Drugs.

BACKGROUND: Social networks determine the availability of drugs, which in turn affects use patterns. Yet, there is some limited evidence that as frequency of drug use increases, people who use drugs increasingly utilize drug dealers. Further, females more often report receiving drugs for free. Studies on these two phenomena are limited by the substances they examine and the countries in which they have been conducted, and they have not been considered together. We examine whether gender differences in sources is moderated by increased frequency of use across four different substances in a web survey of sixteen European countries. METHODS: The European Web Survey on Drugs was collected from 2016-2018 among the national partners of the European Monitoring Centre for Drugs and Drug Addiction. Individuals who use drugs in sixteen European countries completed an online survey. For herbal cannabis, cannabis resin, cocaine, and MDMA, we examine drug acquisition sources by gender and frequency of use. Sources include through dealers and sharing or free, as well as growing and online markets for cannabis. We model each source with logistic regression with chained multiple imputation and a country fixed-effect and clustered standard errors. RESULTS: Across all substances, females who use drugs at low frequencies had significantly lower probabilities than males in using dealers; however, females were equally likely to use dealers when use is frequent. The probability of acquiring drugs for free was higher for females except among those who use most frequently, where the difference became non-significant except for herbal cannabis. CONCLUSIONS: Females and males use dealers to acquire illicit drugs at similar rates when use is more frequent. Except for highest frequency use, females are typically more likely than males to acquire drugs for free. Examinations of supply should consider these gendered differences in acquisition.

The use of multi-national web surveys for comparative analysis: Lessons from the European Web Survey on Drugs.

BACKGROUND: Most comparative drug policy analyses utilise measures of drug use, often from general population surveys (GPS). However, the limitations of GPS are well-recognised, including the small numbers of people who use illicit drugs sampled. Web surveys offer a potential solution to such issues. Therefore EMCDDA conducted a study to assess the potential for using such surveys to supplement information obtained from GPS. METHODS: The European Web Survey on Drugs (EWSD) asked about use of cannabis, amphetamines, cocaine and MDMA in 14 countries from 2016 to 2018. Each participant country translated the questionnaire as necessary and devised its own sampling strategy. Individuals aged 18+, resident in the participant country, who had used one or more of the drugs covered by the survey in the past 12 months were included in the analysis. Participation was anonymous and voluntary. RESULTS: More than 40,000 people completed the survey, with recruitment mostly through social media. Larger samples of users of all drug types than found in GPS were generally obtained. However, the respondent profiles differed markedly between countries, e.g. the proportion aged 18-24 ranged from 30% to 80%. The results relating to use showed both inter-country similarities and differences, e.g. mean daily amounts of cocaine used varied between countries but increases in amounts used with increased frequency of use were similar. Price data showed good external validity. CONCLUSION: Web surveys offer the possibility of collecting information from large numbers people who use illicit drugs quickly and cheaply and can fill important gaps in our knowledge of patterns of use, particularly by recreational users. However, they also have limitations. Standardising questionnaires and approaches to data cleaning and analysis facilitates comparisons between countries but obtaining comparable samples may be challenging. Multinational surveys need to balance standardisation of methods with responsiveness to differing country contexts; our collaborative model does this.

Surveying drug consumption: Assessing reliability and validity of the European Web Survey on Drugs questionnaire.

BACKGROUND: The European Web Survey on Drugs aimed to obtain in-depth data on consumption of cannabis, ecstasy/MDMA, cocaine, and amphetamines in different populations of drug users in 16 European countries. This paper examines test-retest reliability, the consistency and the comprehensibility of the prevalence and frequency of use questions in the Czech part of the survey. METHODS: A baseline web survey was performed (N = 610) with follow-up data collection in a sub-sample of volunteers providing email addresses (N = 158). The baseline sample was self-selecting, responding to advertisements made available through multiple channels designed to attract diverse samples of drug users. Test-retest analysis was conducted for core questionnaire items. RESULTS: Respondents to the follow-up were predominantly socially integrated; 91% reported last year cannabis use, 42% used Ecstasy/MDMA, 23% amphetamines, and 27% reported cocaine use. Test-retest reliability was rated moderate to good (reliability coefficients between 0.55-0.87) for most prevalence items with sufficient sample sizes. Items assessing frequency of use were more reliable for most substances when asking about the exact number of days used, compared to categorical items that implicitly assume a regular pattern of use and were interpreted differently by different respondents. CONCLUSIONS: Simplicity and unambiguity of questions increase the reliability of results. Tools measuring drug consumption need to take into consideration the irregularity of drug using patterns. Question testing is important to increase validity and support a correct interpretation of the data.

Conhecimentos ludopedagógicos na aprendizagem da natação infantil / Ludopedagogical knowledge in children's swimming learning

O presente estudo tem por objetivo analisar o uso dos aspectos lúdicos nas aulas de natação, bem como suas contribuições no processo de ensino-aprendizagem. Trata-se de uma pesquisa qualitativa em que foram entrevistados nove professores de Educação Física que trabalhavam com o ensino da natação infantil. Para análise dos dados, foi utilizada a técnica de análise de conteúdo do tipo análise temática. Os resultados apontam a relevância do lúdico no processo ensino-aprendizagem, que apesar de ser uma prática não rígida, requer tratamento pedagógico, além do fato de que algumas escolas de natação insistem no ensino tecnicista. Conclui- se que é preciso fomentar a manifestação do componente lúdico como forma de potencializar a fruição, o processo educativo e a participação criativa na cultura.

The present study aims to analyze the use of playful aspects in swimming lessons, as well as their contributions in the teaching-learning process. This is a qualitative research, in which were interviewed nine Physical Education teachers who worked with the teaching of children's swimming. To analyze the data, we used the content analysis technique of thematic analysis type. The results point out the relevance of the playful in the teaching-learning process; Which despite being a non-rigid practice, requires pedagogical treatment; And that some swimming schools insist on technical education. It is concluded that it is necessary to promote the manifestation of the ludic component as a way to enhance fruition, the educational process and creative participation in culture.

Nine reasons why ecstasy is not quite what it used to be.

This paper explores the recent resurgence in use of ecstasy/MDMA in Europe and highlights keys areas of continuity and divergence between the ecstasy market of the 1990s and the current MDMA market. Based on a scoping study involving a targeted multi-source data collection exercise on MDMA, it highlights nine areas that have undergone some level of change, linked with both supply and demand for the drug. Factors discussed include: innovation in production techniques; changes in precursor chemical availability; the role of online markets; competition with other stimulants and new psychoactive substances; the increased availability of high-strength MDMA; and the shift from subcultural towards more mainstream use of the drug. The paper proposes that the MDMA on Europe's contemporary market is in some respects a third generation product with a different consumer profile, with implications that responses developed at the time of the drug's earlier iteration, may be in need of a review and revamp.

Real-World Outcomes of Anti-VEGF Treatment for Retinal Vein Occlusion in Portugal.

PURPOSE: Retinal vein occlusion (RVO) is an important cause of visual disability in the modern world. We aim to evaluate the real-world outcomes of patients with RVO treated with anti-vascular endothelial growth factor (VEGF) in Portugal. METHODS: We performed a retrospective, observational, multicenter study including 8 centers across Portugal and 200 patients treated with either ranibizumab or bevacizumab. Data were collected at 3 time points: time of diagnosis (0 time point) and 6 and 12 months after initiating treatment. Demographic and clinical data were collected. RESULTS: Median visual acuity (VA) and central macular thickness (CMT) improved in the branch RVO (BRVO), central RVO (CRVO), bevacizumab, and ranibizumab groups at 6 and 12 months compared to baseline, with CMT improving further only in the CRVO and ranibizumab groups between 6 and 12 months (p = 0.002 and p = 0.001, respectively). The CMT was lower in the ranibizumab group compared to the bevacizumab group both at 6 and 12 months (p<0.02). Median CMT improved in both the good and poor baseline VA groups at 6 and 12 months compared to baseline (p<0.001). Median VA only improved for the group with poor baseline VA at 6 and 12 months of follow-up (p<0.001). Regression analysis identified several baseline variables as predictors of visual outcomes at 6 and 12 months, with different results depending on the analyzed group. CONCLUSIONS: Both treatments were effective, although less effective than results reported in clinical trials. The morphologic response was better with ranibizumab compared to bevacizumab, although functionally there were no differences.

Corneal Elevation Topography in Primary Open Angle Glaucoma.

PURPOSE OF THE STUDY: The purpose of the study was to describe and compare anterior and posterior topographic elevation maps in primary open angle glaucoma patients with functional damage staging and in healthy controls. METHODS: A total of 217 subjects were consecutively recruited, including 111 primary open angle glaucoma patients (patients), and 106 healthy individuals (controls). All patients performed Pentacam HR corneal topography. Mean anterior keratometry and anterior and posterior topographic elevation maps were compared in the central 3, 5, and 7 mm. Humphrey automated perimetry results from the patient group were classified according to the Glaucoma Staging System. RESULTS: Age (patients: 72.32±8.09; controls: 70.82±8.36; P=0.18) and central corneal pachymetry (patients: 541.13±36.98; controls: 548.67±34.56; P=0.12) were similar in both groups. Maximum elevation readings in the central 5 mm were significantly (P<0.05) higher in the anterior (patients: 8.21±8.63; controls: 5.79±3.62) and posterior (patients: 16.17±8.72; controls: 13.92±6.03) corneal topography of the glaucomatous patients, as well as in the anterior (patients: 17.32±20.78; controls: 9.61±5.64) and posterior (patients: 38.81±19.78; controls: 26.38±12.73) central 7 mm. There was a weak but significant correlation between the Glaucoma Staging System stage and both the anterior 5 mm (r=0.397) and 7 mm (r=0.304) maximum, as well as the posterior 5 mm (r=0.233) and 7 mm (r=0.241) maximum. CONCLUSIONS: In patients with primary open angle glaucoma, there is a forward shifting of the posterior and anterior corneal surfaces. This appears to be correlated with more advanced stages of functional damage, pointing to a possible link between corneal structural changes and duration and intensity of elevated intraocular pressure. Further studies may ascertain the potential for this biological marker to be used in monitoring primary open angle glaucoma patients.

Cocaine-related health emergencies in Europe: a review of sources of information, trends and implications for service development.

BACKGROUND: Cocaine-related health consequences are difficult to observe. Data on drug users in health-emergency settings may be a useful source of information on consequences that are not visible via other information sources. METHODS: Thirty European countries submit an annual national report on the drug situation to the EMCDDA. All reports for the period 2007-2010 were analyzed, with particular attention given to auditing cocaine-related mentions. Analysis was also performed in order to identify sources and case definitions, assess coverage, audit cases and, where possible, to identify long-term trends. RESULTS: Considerable heterogeneity existed between countries in their approach to recording drug-related emergencies, with only Spain and the Netherlands having established formal indicators. The highest annual numbers of cocaine-related episodes were reported by the UK (3,502), Spain (2,845) and the Netherlands (1,211). A considerable (2- to 3-fold) increase in the numbers of cocaine-related episodes has been reported since the end of the 1990s in these countries; these increases peaked in Spain and England around 2007/08. CONCLUSIONS: The analysis reported here suggests the need to develop more standardized approaches to monitoring drug-related emergencies. It points to the potential value of developing effective referral links between the emergency and specialized drug services working with cocaine users.

Reducing drug related mortality in Europe - a seemingly intractable public health issue.

Drawing on an analysis of data from over 30 cohort studies, it can be estimated that between 10.000 and 20.000 opioid users die each year in Europe. Typically, annual mortality rates are between 10-20/1000, representing an excess mortality 10 to 20 times greater than expected. Most deaths occur among males in their mid-thirties. Four broad categories of cause of death can be identified: overdoses, diseases, suicide and trauma. While the long term trend in HIV related mortality among drug users is downwards, other causes of mortality have shown little sign of decreasing in recent years. Of particular concern are overdoses which account for 6300 to 8400 deaths reported annually. The fact that deaths have not decreased is surprising given the scaling up of treatment and other services. Opioid substitution treatment in particular is known to be protective and the numbers of those in substitution treatment in Europe has increased dramatically. A number of interrelated factors may help explain this intractable problem. These include: the possibility of an aging cohort becoming more vulnerable; the use of alcohol and other drugs; high levels of ill-health, risk behaviour, and co-morbidity; and social exclusion and marginalisation. Reducing overall morbidity among heroin users remains a key issue for Europe's public health services. More efforts are required to better understand and target both the direct and indirect factors associated with mortality among problem drugs users, if this major health cost associated with drug consumption is to be reduced.