GREECE DRUG SITUATION 2000 - emcdda

REPORT TO THE EMCDDA

by the Reitox national focal point of Greece,

University of Mental Health Research Institute(UMHRI)

GREECE

DRUG SITUATION 2000

REITOX REF/ 2000

University Mental Health Research InstituteDirector: Professor C.N. Stefanis

GREEK REITOX FOCAL POINT

ANNUAL REPORTon the DRUG SITUATION

Submitted to the E.M.C.D.D.A.2000

Plagianakou, S., M.Sc. – Terzidou, M., M.Phil – Yotsidi, V., M.A.

Compilation of data:Maka, Z., M.Sc.

Plagianakou, S., M.Sc.

Siamou, I., B.A.

Terzidou, M., M.Phil.

Yotsidi, V., M.A.

Statistical analysis:Grimani, I., M.Sc.

Spyropoulou, M., M.Sc.

Contact:

Greek REITOX Focal PointUniversity Mental Health Research InstituteP.O. Box 66 51715 601 AthensGreece

tel: 0030 1 65 36 902fax: 0030 1 65 37 273e-mail: [email protected]

Cover Design: Kokkevi, A.

DeskTop Publishing: Angelopoulou, K.

Graphs: Foundoukas, M.

We heartily want to thank our colleague

Chryssi Lyraki for her overall contribution

and support in the preparation of this report

Manina, Stavroula, Vicky

TABLE OF CONTENTS

INDEX/LIST OF ABBREVIATIONS

SUMMARY: MAIN TRENDS AND DEVELOPMENTS

PART I. NATIONAL STRATEGIES: INSTITUTIONAL AND LEGAL FRAMEWORKS………………………………………............…........………. 2

1. Developments in Drug Policy and Responses ………………………………. 2

1.1 Political framework in the drug field……………………………………………… 3

1.2 Policy implementation, legal framework and prosecution …………………….. 5

1.2.1 Drug laws …………………………………………………………………… 5

1.2.2 Prosecution policy: priorities and objectives…………………………….. 8

1.3 Developments in public attitudes and debates…………………………………. 10

1.3.1 Public debates ……………………………………………………………… 10

1.3.2 Public attitudes……………………………………………………………… 11

1.3.3 Media presentation and image of drug use……………………………… 13

1.4 Budgets and funding arrangements …………………………………………….. 14

1.4.1 Funding at national level…………………………………………………... 14

1.4.2 Geographical differences………………………………………………….. 17

PART II. EPIDEMIOLOGY……………………………………………………...........… 19

2. Prevalence, Patterns and Developments in Drug Use …………………….. 20

2.1 Main developments and emerging trends ……………………………………. 20

2.1.1 Drug use in a changing society ………………………………………… 20

2.1.2 Social attitudes ………………………………………………………….. 20

2.1.3 Youth culture …………………………………………………………….. 21

2.1.4 Availability of drugs ……………………………………………………… 22

2.2 Drug use in the population …………………………………………………….. 23

2.2.1 General population surveys …………………………………………….. 23

2.2.2 School population surveys ……………………………………………… 25

2.2.3 Geographical distribution of drug use …………………………………. 28

2.2.4 Discussion ………………………………………………………………... 32

2.3 Problem drug use ……………………………………………………………….. 32

2.3.1 Adolescents and young adults drug users ……………………………. 33

2.3.2 Risk behaviours ………………………………………………………….. 34

2.3.3 Dropping-out of treatment ……………………………………………… 38

3. Health consequences ……………………………………………………………... 38

3.1 Drug treatment demand ……………………………………………………….. 38

3.1.1 Summary of the characteristics of all clients who requested treatment in 1999 ………………………………………………………... 39

3.1.2 Characteristics of new clients in 1999 ………………………………… 40

3.1.3 Different client profiles in different types of treatment ………………. 42

3.1.4 Treatment demand for cannabis ………………………………………. 47

3.1.5 Comparisons of all client characteristics between 1996-1999 …….. 49

3.2 Drug related mortality ………………………………………………………….. 52

3.2 Drug related infectious diseases ………………………………………………. 55

3.3.1 HIV/AIDS …………………………………………………………………. 55

3.3.2 Hepatitis B and C ……………………………………………………….. 55

3.3.3 Tuberculosis ……………………………………………………………... 56

3.4 Other drug related morbidity …………………………………………………........ 56

3.4.1 Psychiatric co-morbidity ………………………………………………… 56

4. Social and legal correlates and consequences ……………………………... 59

4.1 Social problems ………………………………………………………………… 59

4.4.1 Social exclusion …………………………………………………………. 59

4.4.2 Minorities …………………………………………………………………. 60

4.4.3 Community problems …………………………………………………… 60

4.2 Drug offences and drug related crime ……………………………………….. 60

4.2.1 Arrests and charges …………………………………………………….. 60

4.2.2 Convictions and imprisonments ……………………………………….. 61

4.2.3 Drug related crime ………………………………………………………. 63

4.3 Social and economic costs of drug consumption …………………………… 64

5. Drug markets ………………………………………………………………………... 64

5.1 Availability and supply …………………………………………………………. 64

5.2 Drug seizures ……………………………………………………………………. 65

5.2.1 New trends in drug trafficking ………………………………………….. 67

5.3 Price and purity …………………………………………………………………. 67

6. Trends per drug ……………………………………………………………………. 68

6.1 Cannabis ………………………………………………………………………… 68

6.2 Synthetic drugs ………………………………………………………………….. 69

6.3 Heroin/opiates …………………………………………………………………... 70

6.4 Cocaine ………………………………………………………………………….. 70

6.5 Multiple use ……………………………………………………………………… 70

7. Conclusions …………………………………………………………………………. 72

7.1 Consistency between indicators ………………………………………………. 72

7.2 Implications for policy and interventions ……………………………………… 73

7.3 Methodological limitations and data quality ………………………………….. 73

PART III. DEMAND REDUCTION INTERVENTIONS………………………… 75

8. Strategies in Demand Reduction at National Level ………………………… 76

8.1 Major strategies and activities ………………………………………………… 76

8.2 Approaches and new developments ………………………………………….. 77

9. Intervention Areas …………………………………………………………………. 82

9.1 Primary Prevention ……………………………………………………………… 82

9.1.1 Infancy and family ………………………………………………………. 82

9.1.2 School Programmes ……………………………………………………. 83

9.1.3 Youth programmes outside schools …………………………………… 86

9.1.4 Community programmes ……………………………………………….. 87

9.1.5 Telephone help lines …………………………………………………. 89

9.1.6 Mass media campaigns ………………………………………………… 90

9.1.7 Internet …………………………………………………………………… 91

9.2 Reduction of drug related harm ……………………………………………….. 92

9.2.1 Outreach work …………………………………………………………. 92

9.2.2 Low threshold services …………………………………………………. 93

9.2.3 Prevention of infectious diseases ……………………………………… 95

9.3 Treatment ………………………………………………………………………….. 95

9.3.1 Treatments and health care at National level ………………………… 95

9.3.2 Substitution and maintenance programmes ……………………….. 101

9.4 After-care and re-integration ……………………………………………….. 103

9.5 Interventions in the Criminal Justice System ……………………………… 105

9.6 Specific targets and settings ………………………………………………… 107

9.6.1 Gender specific issues ……………………………………………….. 107

9.6.2 Children of drug users ………………………………………………… 108

9.6.3 Parents of drug users ………………………………………………… 109

9.6.4 Drug use at the workplace …………………………………………… 109

9.6.5 Ethnic minorities ………………………………………………………. 110

9.6.6 Self-help groups ………………………………………………………. 112

9.6.7 Alternatives to prison and prosecution …………………………….. 112

10. Quality Assurance …………………………………………………………………. 113

10.1 Quality assurance procedures ……………………………………………… 113

10.2 Treatment and prevention evaluation ……………………………………… 118

10.3 Research ………………………………………………………………………. 121

10.4 Training for professionals ……………………………………………………. 126

11. Conclusions: Future Trends ……………………………………………………. 130

PART IV. KEY ISSUES …………………………………………………………. 131

12. Drug Strategies in European union member states ………………………… 132

12.1 National policies and strategies………………………………………………….. 132

12.2 Application of national strategies………………………………………………… 134

12.3 Evaluation of national strategies…………………………………………………. 137

13. Cocaine and base/crack cocaine ……………………………………………… 138

13.1 Different patterns and users groups……………………………………………… 138

13.1.1 Epidemiological data …………………………………………………….. 138

13.1.2 Data from dependent individuals ……………………………………….. 138

13.2 Problems and needs for services………………………………………………… 139

13.3 Market ………………………………………………………………………………. 139

13.3.1 Purity and price …………………………………………………………… 139

13.3.2 Trafficking, dealing and distribution patterns ………………………….. 140

13.4 Intervention projects ………………………………………………………………. 140

14. Infectious diseases ………………………………………………………………….. 140

14.1 Prevalence of HCV, HBV and HIV among drug users………………………… 140

14.1.1 Hepatitis …………………………………………………………………… 140

14.1.2 HIV/AIDS ………………………………………………………………….. 143

14.1.3 Data on infectious diseases from special studies …………………….. 144

14.2 Determinants and consequences………………………………………………… 146

14.3 New developments and uptake of prevention, harm reductionand care …………………………………………………………………….……… 145

REFERENCES……………………………………………………………………149

References and sources of information ……………………………………………. 150

ANNEX ……………………………………………………………………………………….. 155

Table I. Prevention Centres established by OKANA (1997-2000) ……………………. 156Table II. Treatment units, geographical location & coverage …………………………… 158

CONTENTS OF TABLES

PART I. NATIONAL STRATEGIES: INSTITUTIONAL AND LEGAL FRAMEWORKS

Table 1. Public expenditure on drugs ……………………………………………………. 15

PART II. EPIDEMIOLOGY

Table 2. Use of psychotropic substances by high-school students: datafrom the University of Ioannina survey………………………………………… 27

Table 3. Demographic characteristics of drug users among prisoninmates in 1995 ………………………………………………………………….. 31

Table 4. Needle sharing among Greek IVDUs as reported in differentstudies in 1991-1993 ……………………………………………………………. 35

Table 5. Changes in the risk behaviours of Greek intravenous drugusers between 1993 and 1998…………………………………………………. 36

Table 6. Characteristics of users starting treatment …………………………………… 41

Table 7. Number of individuals seeking treatment in different types oftreatment during 1999…………………………………………………………… 42

Table 8. Number of individuals demanding treatment in 1996 and 1999 ……………. 50

Table 9. Characteristics of drug related death cases in 1995-1999………………….. 54

Table 10. Sources and nature of information on Hepatitis B and C andstatus of collaboration with the Greek GP in 2000…………………………… 55

Table 11. Drug seizures in 1999 made by each of the law enforcementauthorities ………………………………………………………………………… 66

Table 12. Retail and trafficking drug prices in 1999 (in EURO)………………………… 68

PART III. DEMAND REDUCTION INTERVENTIONS

Table 13. Evaluation results of the “Parents’ School” programme of thePrevention Centre “PYXIDA” …………………………………………………… 83

Table 14. Objectives of the school prevention programmes according totheir target-groups ………………………………………………………………. 84

Table 15. Students’ replies regarding changes in attitudes and knowledgefollowing the programme “Prevention of drugs, promotion ofinterpersonal relations and combating academic stress”……………………. 86

Table 16. Staffing of the therapeutic programmes in 1999……………………………… 96

Table 17. Funding sources of the therapeutic programmes ……………………………. 97

Table 18. Specific criteria in the prevention field according to the formalrequirements for quality assurance……………………………………………. 115

Table 19. Structures and types of training in the prevention field ……………………... 127

PART IV. KEY ISSUES

Table 20. Prevalence of HIV and hepatitis in Greek prisoners ………………………… 144

Table 21. Programmes and interventions for combating infectious diseases………… 146

CONTENTS OF FIGURES


Figure 1. Drug use by young club/party goers and the general population ………..… 21

Figure 2. Drug use in the general population by gender …………………………..…… 24

Figure 3. Lifetime drug use in high-school students from the ESPAD study ……..….. 26

Figure 4. Geographical distribution of illicit drug use among high-schoolstudents ……………………………………………………………………..…… 28

Figure 5. Use of psychotropic substances by high-school students inthree major Greek cities…………………………………………………………. 29

Figure 6. Geographical distribution of illicit drug use among the generalpopulation………………………………………………………………..……….. 29

Figure 7. Characteristics of adolescents and young adults drug usersrequesting treatment at “STROFI” in 1998-1999 …………………..………… 34

Figure 8. Risk behaviours among adolescent and young adults drug users ……..….. 37

Figure 9. Sociodemographic characteristics of new clients ……………………….…… 40

Figure 10. Age distribution of clients in drug-free and substitutionprogrammes………………………………………………………………………. 43

Figure 11. Labour status of clients in drug-free and substitutionprogrammes………………………………………………………………………. 43

Figure 12. Age distribution of clients in out-patient and in-patientprogrammes………………………………………………………………………. 45

Figure 13. Labour status of clients in out-patient and in-patientprogrammes ………………………………………………………………..……. 45

Figure 14. Primary substance used by clients in out-patient and in-patientprogrammes …………………………………………………………………..…. 46

Figure 15. Number of substances used by clients in out-patient andin-patient programmes ……………………………………………………..…… 47

Figure 16. Sociodemographic characteristics of cannabis use……………………..…... 48

Figure 17. Number of substances used by cannabis and opiate users …………..……. 49

Figure 18. Labour status of clients demanding treatment in 1996 and 1999 ………..… 51

Figure 19. Living status of clients demanding treatment in 1996 and 1999 …………….. 52

Figure 20. Drug related deaths (1985-1999) ………………………………………….….. 53

Figure 21. Arrests and charges by the Hellenic Police and charges bythe law enforcement authorities (1994-1999) ……………………………..…. 61

Figure 22. Individuals imprisoned for drug law offences (1995-1999) ……………..…... 62

Figure 23. Imprisoned individuals for drug law offences according to typeof offence (1996-1997) ……………………………………………………….… 62

Figure 24. Burglaries in pharmacies in Greece (1991-1999) ……………………..…….. 64

Figure 25. Seizures of heroin, cocaine and herbal cannabis (1991-1999) ……………... 65

Figure 26. Simultaneous use of ecstacy and other substances by 69high-school students and club/party goers ………………………………..….. 69

Figure 27. Number of substances used by clients requesting treatmentin 1996 and 1999 ………………………………………………………..………. 71

Figure 28. Very frequent alcohol consumption among drug users and non-users between 1984 and 1998 ………………………………………..…. 71


Figure 29. Prevention centres established by the OKANA per yearof inauguration ………………………………………………………………..…. 78

Figure 30. Types of therapeutic programmes in 2000 ………………………………….... 95

PART IV. KEY ISSUES

Figure 31. Test results for Hepatitis C as reported by the variousrelevant sources in 1999 ……………………………………………………….. 141

Figure 32. Self-reports for Hepatitis C in 1999 ……………………………………………. 142

Figure 33. AIDS cases among drug users (1985-1999) ………………………………… 143

LL II SS TT OO FF AA BB BB RR EE VV II AA TT II OO NN SS

Term Definition

ESPAD European School Survey Project on Alcohol and Other Drugs

FESAT European Foundation of Drug Help-Line

KEEL Centre for the Control of AIDS & STD’s

KETHEA Centre of Therapy for Dependent Individuals

NA Narcotic Anonymous

NSPH National School of Public Health

OKANA Organization Against Drugs

UMHRI University Mental Health Research Institute

SSUUMMMMAARRYY

MMAAIINN TTRREENNDDSS AANNDD DDEEVVEELLOOPPMMEENNTTSS

A. Epidemiology

Most indicators point at an aggravation of the drug problem in Greece.

Increased number of young people experiment with drugs, mainly forrecreational purposes. The representation of women among drug usersincreases.

Drug use is spreading to all geographical strata and it is quite prevalent tospecial social groups, such as prison inmates.

Dependent users requesting treatment have also increased in both substitutionand drug free programmes. New clients, i.e. those requesting treatment in 1999for the first time seem to share similar characteristics with old clients: they aremostly young males, unemployed, opiate users. Clients in methadonesubstitution programmes differ from clients in drug-free or in-patientsprogrammes, as they are selected following strict criteria.

Cannabis users who demand treatment have a different profile from heroinusers: they are younger, and they use multiple drugs or inject to a lesser extentthan heroin users.

Risk behaviours continue to be exhibited by high percentages of dependentusers. Although AIDS infection is much lower than in other European countries,hepatitis, especially C, is spread to the majority of injecting drug users.

The rate of drug related deaths, which appeared stabilising in the previousyears, increased sharply in 1999.

Due to its geographic position, Greece had always had to deal with drugtrafficking across borders, especially trafficking from Asia and Africa to Europe.The main trafficking route is the sea, although new trends emerge, such as the“mailing” of drugs.

Drug production is a totally new trend for Greece, which was revealed with theseizure of large amounts of precursor substances and amphetamines in aproduction “industry”.

B. Policy

Having adopted since 1987 a more lenient approach towards drug use and drugusers compared to the previous status, Greek legislation on drugs seemsnowadays as being more attuned to the European one by trying to achieve abalance between repressive and preventive initiatives. The emphasis put oneither level of confrontation of the problem seems to follow overall changes ofsocial life. Having taken into account the increase observed in drug useprevalence Greek prevention policy is orientated towards the reinforcement ofprimary prevention activities either by supporting and further expanding PrimaryPrevention Centers or by promoting their inter-communication and cooperation.

Related are also future plans for putting more emphasis on research andevaluation as well as on professional and educational training on primaryprevention. Data regarding problematic drug use indicate, moreover, a need foran increase in availability of treatment programmes, a need that has alreadybeen set as a priority by OKANA as has also been the expansion of treatmentunits for adolescents in many Greek cities.

Initiatives and plans have also been organized at the level of law enforcement.Repressive measures have been undertaken or formed under two majorscopes: frontier drug trafficking and increased criminality observed in particularinland municipalities, whereas plans to facilitate the judicial procedure ingeneral include also re-examination of the drug laws or changes in thesentences’ imposition.

The public bodies that are actively involved in policy making and application atall levels of confrontation, i.e. Ministries, local authorities, treatment andprevention services, are represented in the steering committee of OKANA, whoconstitutes the central coordinating body responsible for policy making at alllevels of prevention. The Central Anti-drug Coordinating Unit, on the other hand,has assumed coordinating and administrative responsibilities at the level ofrepression. However, the combination of the different philosophies of theauthorities involved at all the levels of confrontation should facilitate furthermorea holistic approach to the phenomenon of drugs. Moreover, under the scopethat OKANA has been entrusted with the inter-ministerial coordination, its legalbasis, as has also been argued by the previous All-Party ParliamentaryCommittee, should come under re-examination, so that it would lend it prestige,flexibility and autonomy to act as an intermediary agent more effectively.

Public and political debates have often been raised during the reporting year,mainly due to two major facts: the oncoming parliamentary elections in April2000 and the issue of the administration of drugs besides methadone, that wasset by two governmental members. The political debates were widely hosted inthe press. The latter contributed also to the general formation of the drug useimage. The core of the press argumentation was young generations and druguse as well as the “visualization” of drug addicts as “victims” and of drug dealersas “victimizers”.

C. Demand Reduction

Following the proliferation of the prevention and the therapeutic programmesduring the last three years, emphasis was given in 2000 on the development ofnew services and on the promotion of quality assurance in the demandreduction field. Within this framework, combined efforts from policy makers andprofessionals working in the drugs field focused on acknowledging the gaps atthe provision of services in terms of both quantity and quality as well as ontaking action to respond to the drug users’ needs more effectively.

On these grounds, nine new prevention centres were inaugurated, while healthpromotion programmes that take place under the initiative of the Ministry of

Education were increased. The main focus of policy regarding primaryprevention was on the improvement of prevention interventions, through theestablishment of systematic training in evaluation issues as well as through thereinforcement of co-operation among all the responsible agencies.

Based on research data and clinical experience, new therapeutic and harmreduction programmes were created in order to cover the demand for treatmentagencies at local and regional level as well as to respond to the needs ofspecific groups of drug users. Within this framework, the first methadonemaintenance unit was inaugurated in Athens, many of the existing regionaltherapeutic programmes have expanded their services to adolescents drugusers, and street-work programmes were increased at the local communities.Moreover, an innovative initiative in 2000 was the development of the SupportCentre for Prisoners and Discharged Prisoners in Thessaloniki, which aims atharm reduction, enhancing motivation to treatment, rehabilitation and socialreintegration.

The vocational and social rehabilitation of former drug users was another areaof intervention on which emphasis was laid. Having being initiated in 1998-1999, the development and implementation of vocational training programmeswere systematized in 2000. Moreover, new rehabilitation programmes weredeveloped for former drug users as well as for long-term substitution clients.The Ministry of Labour and Social Welfare continued in 2000 to providesubsidies to ex-addicts and to discharged prisoners who start working at theprivate sector or want to run their own business.

Training of professionals was also reinforced through the publication of neweducational materials, the organization of seminars and conferences on a moresystematic basis and the co-ordination of meetings to exchange experience andopinions. The main themes of these training programmes concerned effectivemethods of intervention in different scopes of work (i.e. prevention at theprimary education, drug counselling, street-work programmes) as well as thepromotion of an evaluation culture in the demand reduction field.

Several interventions ranging from education on safe drug use and safe sex tosyringe exchange, testing and treatment are currently provided by most demandreduction agencies in order to prevent infectious diseases and to promote harmreduction from drugs. However, it appears to be necessary for the respectiveprogrammes to be further expanded, especially at the local and the regionallevel.

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1. DEVELOPMENTS IN DRUG POLICY AND RESPONSES

1.1 Political framework in the drug field

Since the enactment of Law 1729/1987 Greek legislation on drugs adopted amore lenient approach towards drug use and drug users by departing frombeing a clearly corrective policy alone and becoming at the same time apreventive one as well. Differences from the previous legislative statusfocused mainly on the establishment of dissimilar confrontation of addicteddrug users and of drug dealers, on regarding the former as “patients” needingmedical attention and on the emphasis put on prevention. Amendments of the1987 Law ever since as well as enactment of new laws reinforced this morehumanistic model enabling the implementation of harm reduction initiativesand the protection of drug related offenders by acknowledging extenuatingcircumstances for them.

The state’s intention to confront the drug problem in a more comprehensiveway is indicated by initiatives that have been undertaken in regard to severaldimensions of the phenomenon. Repression and prevention policies appearmore balanced and emphasis on either level of confrontation is put followingsocial changes. The acknowledgement and the acceptance on the side of thestate of the existed drug use prevalence, that seemed to be on the rise, aswell as of the existed demand for therapy led to the inauguration of bothdemand and harm reduction activities. On the other hand, drug traffickingthrough and within Greece that is nowadays viewed as part of theinternational organized crime is considered to be facilitated by changes in thenear Balkan countries during the last decade and mainly by the opening oftheir boundaries. Foreigners entering Greece in illegal ways constitute,according to the police, a major problem, since many of them are involved indrug trafficking and assume an important role in the visualization of Greece asa “cross-road for drugs”. The above estimation has led prosecution authoritiesto reinforce the frontier guard without weakening at the same time inlandmanpower.

New developments for the reporting year and plans for the near future arepresented below in regard to three different domains: prevention, repressionand justice

Prevention

The Organisation Against Drugs (OKANA) under the umbrella of the Ministryof Health is the central coordinating body, responsible in policy making in thedomain prevention. OKANA (2000) has published a three year action plancovering all levels of prevention.

P r i m a r y p r e v e n t i o n

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Priorities that have been set by OKANA in regard to primary prevention refermainly to the expansion of Prevention Centers so as to cover every Greekprefecture by the end of 2001 as well as to the increase of OKANA’sPrevention Department manpower both under the scope of protecting andpromoting the prevention centers’ institution. Moreover, to improve electroniccommunication among the centers as well as between the centers andOKANA or their supporter agencies, OKANA plans for the supplying of aunified electronic information system. As regards professionals’ training inprevention, OKANA plans to systematize the training activities’ supervision, topublish respective reference books, to establish libraries in all preventioncenters as well as to cooperate with the Ministry of Education and thecountry’s universities so that prevention training will be included in the basicuniversity education.

S e c o n d a r y p r e v e n t i o n

Data regarding the needs for therapy indicate that the respective planningshould aim at the increase of treatment programmes’ availability. OKANA’spriority is to see to the establishment of new treatment units in cooperationwith the local and scientific authorities. The new units should include drug-freeprogrammes, substitution detoxification and substitution maintenanceprogrammes. Some of them have already been inaugurated. Moreover, aHelp-center and a Mobile Unit are foreseen for North Greece.

The establishment of treatment units for adolescents in many cities is anothermajor priority set by OKANA, who examines the possibility to cooperate withlocal agencies in the respective areas in order to achieve his goal.Educational training for treatment professionals is also among OKANA’s plansas well as cooperation with the Ministry of Education under the scope ofincluding in the university syllabus a special subject about drug addiction.

T e r t i a r y p r e v e n t i o n

In April 2000, a Centre of Vocational Training has been inaugurated byOKANA, subsidized by European Community Pay Office as well as by theMinistry of Labour. The Centre aims at the professional and socialrehabilitation of 90 ex drug-addicts.

R e s e a r c h a n d e v a l u a t i o n

The promotion of research and evaluation is among OKANA’s three-yearaction plan. To achieve an improved organization and coordination ofresearch and evaluation programmes, OKANA sees to enact a Research andEvaluation Department.

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B r o a d e n i n g o f O K A N A ’ s s u b j e c t

The observed correlation of use between legal and illegal substancesestablishes, according to OKANA, the need for an overall confrontation of licitand illicit substances’ use. This realization on the side of both the state andthe public constitutes a prerequisite towards the direction of treatingproblematic alcohol-users and users of other licit substances as well.

Repression

The Central Anti-Drug Coordinating Unit coordinates repression policy againstdrugs that is applied by four public bodies: the Police (Ministry of PublicOrder), the Customs (Ministry of Finance), the Financial and EconomicCrimes Office (Ministry of Finance) and the Coast Guard (Ministry of MerchantMarine). During the reporting year repressive measures have been intensifiedand new plans have been formed under two major scopes: frontier drugtrafficking and increased criminality observed in particular inlandmunicipalities.

The geographical position of Greece constitutes an aggravating factor forfrontier drug trafficking, because of which Greece has been oftencharacterized as a “gateway for narcotics”. To reinforce the frontier guard thepolice have established a frontier-police unit consisting of 2200 men, whereasthe Ministry of Public Order has already started to provide the frontier postswith highly developed electronic equipment. Both initiatives appeared asimperative all the more so since the official enactment of the Schengenagreement in Greece on the 1st January of 2000. Moreover, the Ministryexamines the possible ways for the upgrading and expansion of the PoliceDrug Prosecuting Units and the establishment of respective units in riskyfrontier and urban areas. Frontier policy against drugs has been moreoverreinforced by the bilateral agreement signed between Greece and Turkeyregarding among others the combat against illegal drug trafficking as well asby the agreement memorandum for cooperation signed between the GeneralCustoms Directorate and a private express mail transport company.

To confront inland drug problem the police implemented or is up to implementmeasures, that although they are mainly repressive they touch uponprevention as well. In particular, pedestrian police patrols that have beenestablished by the Ministry of Public Order are considered to contribute to theconfrontation of the urban criminality, whereas among the repressive policyplans is also the establishment of armed city-police units that will becompetent to make assaults in night clubs after accusations for drug dealing.Similarly, the reinforcement of police forces in tourist areas, especially duringthe summer season, in order to combat imported drugs is also underconsideration, as is also testing car-drivers for drug consumption. Besidesrepressive measures, however, the Minister of Public Order plans also theinvolvement of police in the domain of prevention in cooperation with the othercompetent authorities. Police preventive measures will take the form ofinformation campaigns launched by specialized policemen, police presence

5

outside schools as well as cooperation with the local communities for thedetection of causes that lead to drug-related problems.

Justice

In order to overcome overpopulation problems in custodial institutions as wellas to accelerate case hearing process the Minister of Justice is promoting apilot programme that includes a variety of measures. The proposed measuresaim at changes in the legislative status, on the one hand, and in the judicialprocess, on the other. In particular, the entering into force of inactive legalprovisions such as alternative measures to imprisonment is underconsideration as is also the imposition of administrative measures instead ofcriminal penalties for actions of no serious social demerit. Under examinationare also offences included in the Law against drugs, although the direction ofthe in question reform is not known yet.

Moreover, the imposition of strict measures for inexcusable delay in passingjudgements, the reduction in number of trial postponements as well as theestablishment of new courts are planned in order to facilitate and toaccelerate the case hearing process.

1.2 Policy implementation, legal framework and prosecution

1.2.1 Drug laws

• 1987

The 1987 Law ( 1729/87) provided for the legal aspects concerning drugs aswell as for the development of services in the domains of prevention, therapyand rehabilitation. More specifically, drug users were separated in dependentand non-dependent. The latter if arrested for personal use for the first timewere obliged to follow a counseling program. Dependent users havingcommitted any criminal offence were obliged to follow a detoxificationprogram either in prison or in a public hospital. The time spent in treatmentwas equivalent to the time the offender would spend in prison.

• 1993

According to Law 2161/93 OKANA (The Greek Organisation Against Drugs)was established as a self-regulating legal entity under the Ministry of Health.The above law introduced also several provisions such as the criminalisationof precursor substances, the possibility of substitution treatment in specialpublic units, the controlled transportation concept as described in the 1988U.N. Convention and the severe penalties for doctors and pharmacists whodid not follow the rules for drug prescription.

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• 1995

Law 2331/95 clarified that the postponement of the penal prosecution againstdependent drug-law offenders would be possible, if the director of a licensedDrug Treatment Service submitted an official report to the District Attorneydeclaring that the offender had voluntarily begun and was systematicallyattending the treatment provided by the Service. If the offender completedtreatment successfully, prosecution could be permanently suspended.

The above law criminalised also the laundering of all criminal proceeds,including drug trafficking.

• 1996

Law 2408/96 introduced a more lenient treatment of dependent users violatingdrug laws, since offences of dependent users were to be treated asmisdemeanors and not as felonies. In 1997, two amendments of the 1996Law reintroduced the characterisation of drug dealers as “especiallydangerous” and laid down special penalties for dealers selling drugs tochildren.

• 1997

M i n i s t e r i a l D e c r e e 3 3 6 8 2 / 2 7 - 6 - 1 9 9 7

This decree issued by the Ministry of Labour and Social Welfare provides forthe three-years subsidize of employers to employ 290 ex-drug addicts, ex-prisoners and young delinquents. In particular, three out of the fiveprogrammes that have been organized by the Ministry of Labour, refer to thecreation of job opportunities for former drug addicts. Age-range for formerdrug addicts is from 16 to 65 years old and the daily amount of subsidizeranges from 11.7 EUROs (for part-time occupation) to 22 Euros for full-timeoccupation during the third year.

M i n i s t e r i a l D e c r e e 3 3 7 7 9 / 1 5 - 7 - 1 9 9 7

Issued by the Ministry of Labour and Social Welfare, this decree provides forthe subsidize of new free-lancers aged from 18-60 years old. This subsidize isaddressed to former drug-addicts and discharged prisoners. Subsidizeduration is for 24 months whereas the amount of subsidize is 3521.6 Eurosper year. Annual increments are provided for new free-lancers if theirenterprise is created in border, island or downgraded areas.

7

• 1999

L a w 2 7 2 1 / 9 9

Law 2721/99 provided for the more lenient treatment of drug users in case oftrafficking of small drug amounts. More specifically, trafficking of smallamounts of drugs between users proven to be exclusively for personal use issince June 1999 considered as misdemeanor and not as felony, since it canlead to 6 months imprisonment that could be either exchanged with a fine orsuspended.

Moreover the above law provided also for drug-dependent offenders whocommitted some criminal act in order to facilitate drug use. In case this act isnot against human life, personal freedom and physical integrity the offendercan have his penal prosecution postponed or even permanently suspended ifhe achieves detoxification on his own providing that a public hospital orlicensed drug treatment service in Greece or in the European Union verifiesthat his addiction started before the commission of the criminal act. Moreover,his detoxification should be also verified by a licensed drug treatment serviceafter the offender had attended a treatment program for at least six months.

Law 2721/99 included also the establishment of two detoxification units fordrug-dependent prisoners one in Thiva (Central Greece) and one in Chalkidiki(North Greece) aiming at the physical as well as psychological detoxificationof drug-dependent prisoners.

L a w 2 7 1 6 / 9 9

The 2716 Law of 1999 officially provided for the administration of substitutesof drugs in licensed public units and in units of OKANA. Pilot substitutiontreatment programs had been inaugurated in Greece since 1996 by OKANA,with the administration of methadone. According to the above law thesubstitution substances and the conditions of administration will be decided byministerial decrees.

L a w 2 7 7 6 / 1 9 9 9 - P e n i t e n t i a r y C o d e

Law 2776/1999 provides for the establishment of the category specializeddetoxification prison units among the various sorts of custodial institutions.The two established Detoxification Centers for Drug-depended Prisoners wereplaced under this category.

M i n i s t e r i a l D e c r e e 1 4 9 0 2 0 / 2 - 1 2 - 9 9

Signed by both the Minister of Health and the Minister of Justice, this decreeprovided for the formation of the therapeutic programme that will be

8

implemented in the Detoxification Centers for Drug-depended Prisoners. Aspecialized council will select drug dependent prisoners, who should beadmitted in the centers. Three types of treatment programmes will beimplemented within both Centers: a) a drug-free programme for individualsover 21 years of age, b) a drug-free programme for individuals up to 21 yearsold and c) a substitution programme with the administration of methadone.

• 2000

M i n i s t e r i a l D e c r e e 3 1 8 3 / 1 2 - 5 - 0 0

This decree refers to a specific proprietary medicine containingBuprenorphine. Although Buprenorphine is under Table D of the law againstdrugs since 1987, this ministerial decree provides for its administration in theform of the specific medicine exclusively within detoxification centers licensedto administrate substitution substances.

M i n i s t e r i a l D e c r e e 3 8 0 7 / 3 1 - 7 - 0 0

The decree refers to the classification of Norephedrine(Rhenylpropanolamine) as precursor substance under Table I of article 9 inLaw 2161/1993.

M i n i s t e r i a l D e c r e e 3 2 2 5 / 2 - 1 0 - 0 0

Classification of the substances Medetomidine, Atipamezole and Romifidineunder Table C of Law 1729/1987.

1.2.2 Prosecution Policy: priorities and objectives

If someone is arrested for cannabis, heroin or cocaine possession the policeare obliged regardless of the type of substance and the amount seized tocommit the offender to the district attorney, the only authority responsible topress charges against the offender.

Non addicted arrested users are brought to trial without being taken intotemporary custody. Accidental users, who are arrested, are committed to thedistrict attorney but it is possible that they will never be brought to trial.Addicted users, who are arrested, have the possibility to spend some hours ordays at the hospital instead of jail or they are released after the charges havebeen brought against them.

The court decides upon the penalty that will be imposed. According to law2161/93 for the determination of the sentence the court takes intoconsideration the amount of the seized substance, so that it can decide that itwas exclusively for personal use. Moreover, the degree of harm induced by

9

the specific substance and the table into which the substance is classifiedaccording to law 1729/87 is also taken into account before the determinationof the sentence. In practice, there have been cases observed wherepossession of a small amount of cannabis was more strictly punished thanpossession of a small amount of heroin on the grounds that heroin causesaddiction and thus arrested users were in need, whereas cannabis does not.Addicted users go unpunished since detoxification units in prisons, thataccording to law 1729/87 the offender was obliged to attend, do not exist untilnow. Non-addicted users who are arrested for the first time are obliged tofollow a counseling program.

Charges for trafficking of drugs are pressed against the offender accordinglyto the amount of drugs seized or to the information that the police have on theoffender. In case the police are informed that someone is trafficking drugs,they arrest users who obtain drugs from him in order to verify his identity asdrug-dealer and after the positive verification charges against the offender arepressed for trafficking and not for use. In cases of drug trafficking the policeinvestigate the offender’s residence as well, whereas in cases of plain druguse they do not.

The police have set priorities regarding the specific drugs whose traffickingshould be firstly repressed. Heroin is considered as the “hardest” drug andthus it is the one that is prosecuted the most. Right after heroin ranks cocaine,then synthetic drugs and last ranks cannabis.

Users who are also involved in trafficking are committed to the examiningjudge who decides for their temporary detention in case there are reasons forit, e.g. if they are characterised as “especially dangerous”. However, theyshould be brought to trial no later than after 18 months. Addicted usersinvolved in drug trafficking are facing up to 8 years imprisonment, whereasnon-addicted offenders are facing life imprisonment.

Law 2721/99 provided beneficial provisions for drug users who exchangesmall amounts of drugs proven to be exclusively for personal use. Traffickingof small amounts of drugs between users is considered as misdemeanor thatcan lead to 6 months imprisonment that could be either exchanged with a fineor suspended.

Dependent offenders having committed some property crime in order tofacilitate drug use could until June 1999 follow a licensed detoxificationprogram according to law 2331/95 instead of being sentenced to prison underthe condition that the treatment service would submit an official report to theDistrict Attorney declaring that the offender had voluntarily begun and wassystematically attending the treatment provided by the service. The time spentin treatment was equivalent to the time the offender would spend in prison. Ifthe offender completed treatment successfully prosecution could bepermanently suspended and if he was convicted for property offences thatwere committed before he begun to attend the treatment program, theimposition of the penalty was suspended for no less than 3 and no more than6 years under the condition that the offender remained detoxified.

10

In June 1999, Law 2721 was passed that stipulates the above beneficialprovisions also to those addicted offenders who have committed someproperty crime and who can achieve detoxification without attending acomplete licensed treatment program. The necessary pre-conditions for theimplementation of the above benefits are the following: 1) the verification of apublic hospital or licensed treatment program that the addiction of the offenderhad started before the commission of the crime and 2) detoxification shouldbe verified by a licensed drug treatment service after the offender hadattended a treatment program for at least six months.

1.3 Developments in public attitudes and debates

1.3.1 Public debates

Drug issues become often a topic of public and political debates all the moreso before parliamentary elections, which was the case in Greece for thereporting year. Platforms of the candidate parliamentary parties includedissues referring to drugs either questioning the effectiveness of the existinggovernmental policy or forming specific proposals targeting on theconfrontation of the problem.

The issue, however, that prevailed over the social, scientific and politicaldebates was raised at the end of 1999 by two governmental members andreferred to the expansion of substitution treatment. In particular, bothmembers argued in favor of the controlled administration of other substancesas well, besides methadone, to which drug addicts were addicted.Administration, as it was argued, should take place in public hospitals andmedical centers to “drug addicts at a late stage”. Their proposal, they clarified,rested on the need of keeping drug addicts out of the drug markets as well ason the positive results that were observed in countries were such initiativeswere implemented, especially as regards the decrease in the number ofdeaths and criminal offences. On the other side, reactions were raisedreferring to the vagueness of the term "drug addicts at a late stage" as well asto the “medicalization” of the problem. Solutions to the problem, as theopponents of that proposal argued, should not be based on maintenanceprograms but on the exploration of the causes of drug addiction. Moreover,they called upon morality issues as well as on practical difficulties inimplementing such a proposal, due to the lack of the appropriate legalframework, whereas they objected that such initiatives, that had took placeelsewhere were still under evaluation.

Another issue that raised a lot of political criticism was lack of definition of theterm “small drug amounts” that determines if a quantity is possessed (Law2161/1993) or disposed of (Law 2721/1999) for personal use. The Minister incharge argued that the definition of “small amount” for every addictivesubstance is not possible since new drugs in new form and package are everyday on the “market”.

11

Finally, in the face of the Greek parliamentary elections in April 2000 politicalproposals outlined by the Youth Movements of several parties includedamong others decriminalization either of “soft” drug use or of all drug use.Thus, once again, the debate on the discrimination between “soft” and “hard”drugs and on the decriminalization of use that prevail over the general socialdialogue during the last years was reflected in the political agenda.

1.3.2 Public attitudes

A view on the attitudes of the public towards drug issues is usually formed bythe concentration of survey data carried out either by scientific or privateorganizations as well as by monitoring responses of certain professional,political or broader social groups towards matters of special public interest.

A nationwide drug survey on the drug prevalence carried out in 1998 by theUniversity Mental Health Research Institute showed among others that themajority of the 12-64 year old population believed that as much use asdistribution of cannabis and heroin should not be legalized1. However, greatdifferences were observed between the attitudes of the public towardscannabis and heroin as well as in the changes of those attitudes towards eachsubstance over the years. The legality of cannabis possession for personaluse was supported by 22.4% of the population in 1998, whereas therespective percentage for heroin was 7.5%. In 1984 results from the previousoriginal survey showed that attitudes in favor of possession for personal usewere at 4.7% for cannabis and at 2.0% for heroin. Moreover, in 1998 22.7%believed that cannabis sale should be placed under governmental control (therespective rate in 1984 was 9.9%), whereas 10.8% believed the same forheroin (the respective rate in 1984 was 7.3%). It is, thus, strongly indicatedthat attitude changes over the years towards drug use refer mainly tocannabis, a substance for which 53% of the young adults believed that it washarmless or slightly harmful in 1998 ( Kokkevi et al. 2000).

Use and attitudes towards use seem to be strongly correlated, at least amonghigh school students, as it is also argued in a doctoral dissertation thesispublished in the current year (Dimitriou 2000 unpublished dissertation) . Thesurvey carried out in 1997 in three large Greek cities (Athens, Patra andIoannina) on 2123 students of the 12th grade showed that the use ofpsychotropic substances was significantly higher among students with a morepermissive attitude. In another research, qualitative this time, drugs amongteenagers were approached experimentally within the framework of the socialrepresentations theory (Katerelos in press). Considering illegality andaddiction as the central elements in the social representation of narcotics itwas found that addiction seems to have a larger impact than illegality amonghigh school pupils. Greek adolescents consider as drugs those substancesthat are both illegal and addictive and think of them as being able to combinenegative and positive effects at the same time (i.e. death and love, danger

1 Unpublished data of the 1998 nationwide survey “Psychosocial Factors and Health” carriedout by the University Mental Health Research Institute.

12

and cease of pain, destruction and joy). This quality, as it was found in thestudy, is what makes these substances worth to try. In his attempt to form aproposal, the author argues that although legalization would reduce theyouth’s indifference in drugs, this should not automatically mean rise ofinterest in them. Should one hypothesize that this means rise of interest in theshort term, one should at the same time hypothesize that in the long terminterest would subside, since in every legal substance both negative andpositive effects seem to be devalued with time.

Besides the aforementioned scientific studies, however, private initiatives topoll public opinion, that were carried out on behalf of Athenian dailynewspapers showed that drugs rank high on the list of social problems forwhich the public expects immediate governmental intervention.

Moreover, in regard to specific aspects of the problem a daily Atheniannewspaper “Eleftherotypia” carried out a small survey on attitudes towards thecurrent legislation on drugs and the possible future amendments among 65out of 300 Parliamentary Members. A percentage of 65% believed that therepressive policy on drugs that was being followed had not been effective.The vast majority (93%) of the respondents considered drug users as“singular patients” needing sanitary attendance, whereas at the same time72% believed that prosecution and imprisonment aggravated the drug-problem among addicts. As regards the expansion of substitution treatment,58% argued in favor of the expansion of substitution treatment withmethadone but 46% against the experimental administration of heroin to drugaddicts. The experimental administration of heroin as well as thedecriminalization of cannabis was supported by almost 24% of theparticipants (Source: “Eleftherotypia” 16/10/1999).

The proposal of the two governmental members (see also Chapter 1.3.1Public debates) regarding the controlled administration of substances towhich drug addicts were addicted led several professional unions to take astand on the expansion of substitution treatment. In particular, the Associationof Hospital Doctors in Athens and Piraeus opposed the administration ofmethadone and heroin under medical prescription in public hospitals.According to their view, this would turn them into supporters of addictionmaintenance as a way of life and into social control authorities, whereas whatwas needed, as they stated, was a serious speculation on the causes ofaddiction. With similar skepticism encountered other professional and socialgroups this proposal as well, such as psychologists, legal persons, and theWomen Confederation of Greece. On the other side, the Association ofDoctors in Chania (South Greece) argued for the expansion of substitutiontreatment with methadone all over Greece and for the administration of heroinin public hospitals. In the same area (Hania), in June 2000, many drug addictscampaigned for the establishment of a new drug therapy center andmethadone substitution programme, proposal that was supported by Chania’smayor, local church authorities and the Organisation Against Drugs (OKANA).

13

1.3.3 Media presentation and image of drug use

The Greek Focal Point since 1999 has started the systematic collection ofdaily press publications concerning drugs in order to monitor the way, in whichthe mass media cover and present the phenomenon. Because drugs areconsidered a multidimensional phenomenon one should expect that the mediacoverage should refer to all the known factors associated with it. In fact, manyaspects are covered (legal, political, scientific, and social) although lawenforcement and law violation, as reflected in the police reports presented inthe daily press, outnumber all other publications. Thus, emphasis is putmainly at the legal aspect of the phenomenon and the most appropriatesource to enlighten the situation and to contribute to its solution are, accordingto the press, the politicians through their legislative competence. Although notequally, various aspects of the phenomenon are covered by the press.Certain activities developed within the domain of primary and secondaryprevention, results from research projects, scientific analyses and viewsreceive occasionally its attention.

From all the different drugs, cannabis and heroin receive most attention,although frequent references to synthetic drugs have also been noticed duringthe reporting year. However, besides some rare press releases concerningdomestic epidemiological data on synthetic drugs, the majority of such presspublications are based on data drawn from the foreign news reports. Onecould infer that although the press is not dealing with a local extendedphenomenon, by borrowing foreign data it presents them as beingrepresentative for the Greek situation as well. Ignorance of the cultural aspectof the phenomenon by the press has also been ascertained in the past (Tsili1994), while exploring the drug addict’s image in Greece during the decade1980-1990. Trying to understand the construction of the initial image of thedrug addict in Greece, Tsili traced back in the early 80’s the first presspublications on drug addiction. She argued that the articles published thenwere mainly based on foreign data and bibliography due to lack of nationalevidence. The press handled the “imported” material by using knownjournalistic tricks such as exaggeration, misleading and excessive emphasison the danger associated with drugs. The image of the drug addict during the80’s was that of a “patient”. Drug addiction had become an issue thatdifferentiated the older from the younger generation, since, as it waspresented by the press, it referred mainly to young people, victims of thesociety and of drug dealers.

Nowadays, the mass media image of drug users resembles to that of theprevious decade. Drug addicts are still considered as “patients” and victims,whereas drug dealers as victimizers. Although the blame is put partially onsociety as a whole, the problem often ceases from being a broader socialproblem and becomes exclusively a political one. Expansion of drug use isconsidered to be the result of poor governmental initiative and it is thegovernment that should eliminate the problem. Although “drugs” is a topic thatraises permanently a lot of political debates in Greece, the oncomingparliamentary elections in April 2000 intensified the political argumentationaround it.

14

Young generations and drug use continue to constitute the core of pressargumentation only now the age presented is even younger, since frequentmentioning and analyses of drug circulation within schools, based mainly onindividual events, were observed during the reporting year.

Moreover, during the first half of 2000, many newspapers started the mappingof the local open drug scenes in greater Athens. Thus, certain squaresdowntown or even whole municipalities where characterized as "sinks of drugdealing” promoting the further stigmatization of particular areas.

1.4 Budgets and funding arrangements

1.4.1 Funding at national level

In order to overcome the difficulties, that are usually faced in isolating thegovernmental authorities’ budget on drugs, the Greek Focal Point drew on theestimation of the Ministry of Finance for the realization of the 1999 budget ofall involved Ministries and state authorities (Ministry of Finance 1999). Lawenforcement data on drugs for 1999 were also asked from the authoritiesinvolved in the drug confrontation together with the overall number of lawenforcement data and data on their manpower. Since the funding figures refermostly to the overall budget of each authority, the combination of all the fourabove-mentioned components is supposed to facilitate the estimation of fundsthat concern drugs. All data refer to 1999 and funding figures are presented inEURO. Drachma conversion in EURO is calculated at 340.75 drch per EURO(Table 1).

15

Table 1: Public expenditure on drugs

LAW-ENFORCEMENT DATA

Police

Budget of all national police forces 898.6 millions EURO

Police Manpower 45,000

Police Manpower specialising in the fightagainst drugs 1,200

Frontier- police Manpower (among theirmain tasks is the fight against the drugs) 2,200

Case files for drug offences established bythe Police

7,014 (number of individualscharged: 10,626)

Total number of case files established bythe Police Data not available

Coast Guard

Budget of Coast Guard 517.8 millions EURO

Coast Guard Manpower 4,691

Case files for drug offences established bythe Coast Guard 166 (number of individuals charged: 226)

Total number of case files established bythe Coast Guard 4,590

Financial and Economic Crimes Office

Budget of the Financial and EconomicCrimes Office 14 millions EURO

Financial and Economic Crimes OfficeManpower 1,452

Case files for drug offences established bythe Financial and Economic Crimes Office 9 (number of individuals charged: 15)

Total number of case files established bythe Financial and Economic Crimes Office 518,764

(continued to next page Ê)

16

(continued from previous page È)

Customs

Customs budget 1.5 millions EURO

Customs Manpower 3,981

Case files for drug offences established bythe Customs 35 (number of individuals charged: 43)

Total number of case files established bythe Customs 7,110

Justice

Budget of the Courts 244.4 millions EURO

Number of prosecutions for drug offences 10,9101

Total number of prosecutions Data not available

Custodial institutions

Budget of all custodial institutions 50.2 millions EURO

Number of persons imprisoned for drugoffences 2,0692

Total number of persons imprisoned 4,2462

PREVENTION AND TREATMENT

State budget of prevention centres andprevention programs 3.46 millions EURO

Budget of institutions specialising in drugprevention (prevention centres)3 0.9 million EURO

State budget of institutions specializing intreating drug addiction4 14.3 millions EURO

Budget of Health Expenditures 1424.6 million EURO

RESEARCH AND ACTION AT INTERNATIONAL LEVEL

Amount spent on research5 0.13 million EURO

Amount spent on international level6 0.09 million EURO

1 Relevant data are not available in the Ministry of Justice. The estimation is made by theGreek

Focal Point and is based on the number of individuals charged by all ProsecutionAuthorities.

However, there are cases where charges are pressed against individuals who have notbeen

arrested yet.2 According to 1991 population census data.3 The data refer to the state budget. Prevention centres are also subsidised by localauthorities

(not available data).4 Data refer to KETHEA and OKANA 1999 public budget. “18 ANO” (Psychiatric Hospital of

ATTICA) and the “Drug Dependency Treatment Unit” (Psychiatric Hospital of Thessaloniki)were not included since the Ministry of Health has not provided the relevant data yet.

17

5 Data refer only to OKANA.6 Data refer to OKANA. Included are UNDCP and participation in interstate projects

Figures concerning, the overall 1999 state expenditures, the Gross DomesticProduct and the population are presented below in order to facilitate aproportional estimation of the Greek public expenditure on drugs.

All state expenditures 32.9 million Euros

GDP1 111.7 million Euros

Population2 10.26 millions

1 1997 data Based on estimations of the Ministry of Finance3 The data refer to the state budget. Prevention centres are also subsidised by localauthorities

(not available data).

As regards evaluation and training, isolation of the respective funds is difficultto achieve. Most organisations implement internal or external evaluationprojects using part of their total budget, whereas professionals’ training cost inthe domain of prevention is included in the total budget of the demandreduction activities. Moreover, data on the state budget regarding nationaltraining institutions in the drug field are not available yet.

1.4.2 Geographical differences

An estimation of the geographical distribution of funds and budget on drugs ispossible by an overview of the local and regional distribution of competentservices. The vast majority of therapeutic services are located in Athens,some are located in Thessaloniki and a proportional smaller number isallocated in other urban areas. Moreover, research on drugs is mainlydeveloped within Athenian institutions and organisations indicating also anunequal funds distribution.

Nevertheless, attempts are being made for a more balanced allocation at thelevels of primary and secondary prevention. Conditions of prevention centers’operation for the first three years provide that up to 50% of their yearly budgetshould come from local authorities. Further to the first three years the localauthorities undertake overall funding of prevention centers. Moreover, amongOKANA’s plans is also decentralisation of activities as well as theestablishment of new treatment programmes at local and regional level.

18

NEW INFORMATION

Ministerial Decree 33682/27-6-97 : Employers subsidize for new jobopportunities creation, for the employment of former drug- addicts, formerprisoners and young delinquents, date of adoption: 26/6/1997

Ministerial Decree 33779/15-7-97 : Subsidize of new free-lancers former drug-addicts and former prisoners, date of adoption: 15/7/1997

Law 2776/1999 : Penitentiary Code, date of adoption: 22/12/199, entry intoforce: 24/12/1999

Ministerial Decree 149020/2-12-99 : Treatment Programme of theDetoxification centers for Drug-dependent Prisoners, date of adoption:2/12/1999, entry into force: 15/12/1999

Ministerial Decree 3183/12-5-00 : Subjection of proprietary medicine underprovisions of Law 1729/87, date of adoption: 12/5/00, entry into force: 24/5/00

Ministerial Decree 3807/31-7-00 : Subjection of substance under theprovisions of the law against drugs, date of adoption: 31/7/00

Ministerial Decree 3225/2-10-00 : Subjection of Substances under theprovisions of the Law against drugs, date of adoption: 2/10/2000, entry intoforce: 11/10/2000

OKANA’s Action Plan for the years 2000-2003: The reality about drugs andabout the measures of dealing with the drug problem: Prevention-treatment-rehabilitation, issued by OKANA in May 2000.

19

PPAARRTT IIII

EEPPIIDDEEMMIIOOLLOOGGYY

20

2. PREVALENCE, PATTERNS AND DEVELOPMENTS IN DRUG USE

2.1 Main developments and emerging trends

2.1.1 Drug use in a changing society

The increase in drug use in the last five years in Greece implies its spread toa wider social group, consisted mainly of young people. Social changesoccurring in the eighties decade, such as urbanisation, and immigration mighthave played a role, in that traditional values became less important to youngpeople that they used to be. Young Greeks were ready to adopt features ofentertainment culture and life style from other European countries and theUSA, one of them being substance use. In the last few years illicit drug usehas taken the form of an epidemic spreading to more socially integratedgroups of people, mainly young. Greek drug users in 2000 are not asmarginalised as they used to be ten or fifteen years ago and they consumeillicit substances mostly for recreational purposes.

Ecstasy was introduced in Greece during the second half of the nineties, witha simultaneous rise in other synthetic substances use. Nevertheless,cannabis users form the largest group of users. The epidemiological profile ofcannabis users has changed between 1993 and 1998; data from high-schoolstudents surveys show that in 1998, compared to 1993, cannabis userspresented less psychopathological characteristics and they were bettersocialised (Maka et al. 1999).

2.1.2 Social attitudes

Increased social tolerance and increased drug consumption are highlyassociated. Data from epidemiological surveys conducted in 1998 indicatethat the perception of cannabis use as harmful has decreased considerably,mainly after 1993. The percentage of students who consider cannabisexperimentation harmless or slightly harmful increased significantly in 1998(38.8%) compared to 1993 (23.3%), a trend which parallels cannabis use inthe 1993-1998 period (Kokkevi et al. 2000b). Similarly, among the 18-24 yearolds the percentage of those who perceived the experimentation withcannabis as harmless or slightly harmful increased significantly from 39% in1984 to 53% in 1998. The leniency that already existed towards use of licitsubstances such as psychoactive medicines and alcohol, is in 1998 observedtowards cannabis use as well (Kokkevi et al. 2000a).

This shift in attitudes forms part of the social context created by the ongoingdebate on the discrimination between "soft" and "hard" drugs and thedecriminalisation and legalisation of cannabis use mainly instigated by themedia.

Among University Students a considerable proportion admitted in 1995 thatthey did not know whether cannabis was more harmful than cigarette smoking(37.2%) or than alcohol (42.1%), while about 20% regarded cannabis use as

21

less harmful. Around 30% of the students reported that cannabis causespsychological dependence, 17% that it causes physical dependence and6.9% of students believed that cannabis caused both psychological andphysical dependence. About a third of the students were unaware whethercannabis caused any kind of dependence and whether the user could stop atwill without needing medical support (Marcelos et al. 1997).

2.1.3 Youth culture

Quantitative and qualitative studies on drug use conducted from 1997onwards have attempted to draw the picture of the contemporary Greek youthculture in association with drug use.

According to data from the European study "Nightlife in Europe andrecreational drug use", conducted in Greece by the University Mental HealthResearch Institute, young people (18-24 years old) who frequented clubs andparties in Athens reported illicit drug use at higher percentages (41.4%) thanpeople of the same age group from the general population in Athens (31.7%)(Figure 1). Lifetime cannabis use coincided with overall drug use in both theclub/party goers and the young people from the general population. Cocaineand ecstasy followed with a prevalence of 10.1% and 9.3%, respectively forthe club/party goers, while for the general population the prevalence wasremarkably lower (4% for cocaine and 1.3% for ecstasy). This may indicatethat ecstasy is strongly associated with recreational places. Among club/partygoers, those who reported use of synthetic drugs, seemed to avoidsimultaneous use of other licit or illicit substances, being probably betterinformed than young people from the general population (Kokkevi et al.1998a).

Figure 1: Drug use by young club/party goers and the generalpopulation

SOURCE: Kokkevi et al. 1998a

41,4 41,3

9,3 10,1

31,7 30,7

1,34

0

5

10

15

20

25

30

35

40

45

Any Illicit drug Cannabis Ecstasy Cocaine

%

Club/party goers 18-24

General population 18-24

22

Concerning qualitative data derived from the same study, club/party goersreport as main reasons for drug use during entertainment the "thoroughunderstanding of music", "relaxation" and "improvement of communicationability". According to the interviewees, experimentation with drugs offersspecial intellectual and emotional experiences and that "conscious use" helpslimiting drug use behaviour to the aforementioned purposes. Consequently,they maintain that use of drugs should be limited to recreational purposes andexcessive use, which may entail dependence, or polydrug use should beavoided since such behaviours contradict the recreational character of druguse. It is also reported that the extent of risk of each drug varies; duringnightlife entertainment, they tend to use drugs, which they considered lessaddictive. However, several club/party goers dissociate drug use fromentertainment, stressing that some music scenes are developing a movementof drug –free entertainment.

Users of cocaine or synthetic drugs are more likely to engage in “extremebehaviours” (behaviours that involve some kind of risk) and “do crazy orslightly dangerous things” (20% and 53%, respectively) than non-users (2%and 18% respectively) (Siamou et al. 1999).

The consumption of cannabis, synthetics or cocaine tends to be related topetty delinquent behaviours, such as driving a car without a license orshoplifting, to a larger extent than non-use is (Siamou et al. 1999).

Interviews with key persons revealed that young people consume drug beforethey visit the club. In some clubs there is also dealing besides use; this makesthem particularly popular among young users. Use seems to be higher inprivate open-air parties, as there is protection by the organisers. According tothe Police, such parties may be in rare cases organised by drug dealersthemselves (Calafat et al. 1998).

2.1.4 Availability of drugs One of the factors associated with the increase in drug use is increasedavailability. Epidemiological data from the 1998 surveys indicate that theperception of availability of drugs, and marijuana especially, has changedgreatly over the last 15 years. The majority of students in 1998 (67.2%)consider easy or very easy to find cannabis, compared to 39% in 1993(Kokkevi et al. 2000b). Similarly, in the general population, the percentage of those who perceivecannabis and heroin as easily available has doubled compared to 1984. In1998, almost 70% of the total population consider cannabis as easilyavailable, whereas 50% think the same for heroin. In 1984, the respectiverates were 34.5% and 26.2%.

On the other hand, the decrease in the prevalence of consumption ofpsychoactive medicines noted between 1984 and 1998 in the general and

23

school populations, can probably be attributed to their limited availabilityfollowing the implementation of stricter legislation for their prescriptiontowards the end of the eighties and other policy measures. New combinations of known drugs appear to be emerging: heroin, cocaineand ecstasy with pharmaceutical drugs (benzodiazepines, tranquilizers) orwith LSD and ketamine. Moreover, it seems that heroin or cocaine usersexperiment with new patterns of use, such as swallowing heroin and cocainein a cigarette paper.

2.2 Drug use in the population

Illicit drug use in Greece is increasing in prevalence and spreading into widersocial groups. In the last two years the increase is mostly evidenced inindirect indicators since the most recent epidemiological surveys are at leasttwo years old.

2.2.1 General population surveys

Trends in the general population drug prevalence exist since 1984 and arebased on the nationwide epidemiological surveys that the University of Athensand subsequently the UMHRI have conducted in 1984 and 1998 (Kokkevi andStefanis 1993; Madianou et al. 1993; Kokkevi et al. 2000a). Both surveysfollowed the same methodology and very similar questionnaires. Themethodology and the main findings were discussed in the 1998 and 1999National Reports. Below is a brief summary.

Objectives: Ø Prevalence rates, trends, attitudes

Samples: Ø Nationwide, multistage, probability, stratified accordingto the degree of urbanisation

Ø Size: 4,297 in 1984 and 3,752 in 1998

Ø Age range: 12-64 years

Data collection: Ø Personal interview, based on a structured questionnaire.

Main trends: Ø Overall illicit drug use prevalence became three timesas high between 1984 and 1998 (from 4% to 12.2%)

Ø In 1998, higher percentages were observed in:

- men, who had three times the lifetime prevalencecompared to women, (18.8% and 6% respectively),and

- yound adults, aged 18-35 (22%).

Ø Cannabis remained the most popular illicit drug (12.1%).

24

Although illicit drug use remained a male phenomenon during the years,experimentation with illicit drugs or occasional use, seemed to have increasedfor young women, aged 18-24, much more so than for their malecounterparts (Figure 2).

Figure 2: Drug use in the general population by gender (18-24)

SOURCE: University Mental Health Research Institute, 1998

The lifetime prevalence in 1998 compared to 1984 was almost six times ashigh for women aged 18-24 years (12.1% in 1998, 2.5 in 1984), while for themen of the same age was less than three times as high (31.9 in 1998, 13.3%in 1984). The same ratio was observed in last year's prevalence. Regardingmore regular use, differences were even greater: five times as many menreported use in the last month (10.1% in 1998, 2.5% in 1984), while thepercentage of women in 1998 was 15 times as high as in 1984.”

Men

13,3

7,1

2,5

31,9

20,2

10,1

0

5

10

15

20

25

30

35

40

Lifetime Last year Last month

%

1984

1998

Women

2,5

0,60,2

12,1

6,1

2,9

0

2

4

6

8

10

12

14

Lifetime Last year Last month

%

1984

1998

25

Women aged 25-35 appeared to have significantly decreased their age at firstillicit drug use, by 3.5 years in the last 15 years.

2.2.2 School population surveys

T h e U M H R I s u r v e y s

Epidemiological data on drug prevalence in the student population derive fromstudent population surveys, conducted by the University of Athens and theUMHRI since 1984. Nationwide surveys were conducted in 1984, 1993 and1998 (Kokkevi et al. 1993; Kokkevi and Stefanis 1994; Kokkevi et al. 2000b).All surveys used the same methodology and similar questionnaires, which arediscussed in details in the two previous Reports.


Samples: Ø Nationwide, three-stage, stratified, probability

Ø Size: 10,814 in 1984, 10,543 in 1993 and 8,557 in 1998

Ø Age range: 13-18 years

Data collection: Ø self-completed questionnaire, administered in class byresearch assistants

Main trends: Ø the increasing trend in overall illicit drug use obvious in1993, compared to 1984, resulted in a sharp increaseafter 1993, where the percentage of students reportingdrug experimentation or use doubled (from 6% in 1993to 13.7% in 1998.

Ø Cannabis, and solvents presented the highestprevalence

T h e E S P A D s t u d y

The ESPAD study in Greece was conducted by the University Mental HealthResearch Institute (UMHRI) in Autumn 1999. The ESPAD protocol was usedand the Greek version of the ESPAD questionnaire.

26


Sample: Ø Nationwide stratified, probabilityØ Size: 2,205

Ø Age: 16 year olds (born 1983)

Data collection: Ø Self-completed questionnaire, administered in class byresearch assistants

Main findings: Ø Overall illicit drug use was reported by 9.7% of students,the majority being cannabis users (lifetime cannabisuse= 8.6%). Ecstasy seemed to be the second mostpopular illicit drug (2.1%), while inhalants use was14.2% (Figure3).

Ø The mean age at first drug use was 15 years. Use ofinhalants and amphetamines started at 14 years.

Figure 3: Lifetime drug use in high-school students from the ESPAD Study


Finally, a survey carried out in 1994 by the Municipality of Athens in a sampleof 153 schools in Athens provided similar results to those from the 1993school population survey (Fakiolas and Armenakis 1995).

T h e U n i v e r s i t y o f I o a n n i n a s c h o o l s u r v e y

The Medical School of the Univesrity of Ioannina conducted in 1997 anepidemiological survey on drug use in high school students from schools inAthens, Patras (city with approx. 153,000 inhabitants) and Ioannina (city with

14,2

2,1

1,4

1,7

0,9

8,6

9,7

0 2 4 6 8 10 12 14 16

Inhalants

Ecstasy

Cocaine

LSD or otherhallucinogens

Amphetamines

Cannabis

Any illicit drugs used

%

27

approx. 57,000. inhabitants). The main aims of the survey were to investigatedrug prevalence in high-school students of the country's capital, Athens, andtwo major Greek cities which combine traditional and modern industrialelements (Dimitriou 2000 unpublished dissertation).

Objectives: Ø Prevalence rates, cross-cities comparison, attitudesSample: Ø Stratified, probability in 3 Greek cities

Ø Size: 2,109Ø Age range: 16-17 years

Data collection: Ø self-completed questionnaire, administered in class byresearch assistants

Main findings:(Table 2)

Ø Experience with psychotropic substances (includingunprescribed use of tranquillisers) was reported by 8.2% ofthe students, 13% of boys and 4.3% of girls

Ø Boys outnumber girls in both occasional and regular useØ Cannabis was by far the most popular drug, while other

substances presented quite low percentages.

Table 2. Use of psychotropic substances by high-school students:data from the University of Ioannina survey

Total Boys Girls

(2,109)%

(970)%

(1,139)%

Lifetime

Overall use (at leastonce)

8.2 13.0 4.3

Occasional use 5.0 7.4 3.1

Regular use 3.2 5.6 1.2

Lifetime overall use

Cannabis 7.6 11.9 4.5

Opiates 1.7 1.9 0.9

Cocaine 1.1 1.1 0.9

LSD 0.3 0.7 0.5

Ecstasy 0.4 0.7 0.1

Amphetamines 0.3 0.4 0.3

Tranquilisers 1.2 2.1 0.5

SOURCE: Dimitriou 2000

28

T h e U n i v e r s i t y s t u d e n t s s u r v e y

The University of Ioannina conducted a survey on a sample of 1,057 studentsof in north-western Greece, aiming at investigating the prevalence ofcannabis use and attitudes towards it. Data collection was made by ananonymous questionnaire distributed to students. Cannabis experimentationwas reported by 17.9% of the students and regular use by 8.7%. A muchhigher prevalence of lifetime use of cannabis was observed among males,24.8%, compared to females, 13.5%. In male students the proportion of thoseregularly using cannabis was 14.4%, while in female students it was muchsmaller, 5.1% (Marselos et al. 1997).

2.2.3 Geographical distribution of drug use

S c h o o l p o p u l a t i o n d a t a

The geographical distribution of illicit drug use according to data for theUMHRI school surveys in 1984, 1993 and 1998 are presented in Figure 4.

Figure 4: Geographical distribution of illicit drug use amonghigh-school students


Athenian high-school students presented the highest percentages of drug use(18.8%), followed closely by students from Thessaloniki (16.9%). Theincrease in 1998 compared to 1993 in these two big cities is equally large.Drug use in urban areas (cities with 10,000 inhabitants or more) had alsomore than doubled in these 5 years (1993-1998), while the increase in semi-urban or rural areas (towns/villages with 2,000-9,999 inhabitants) is somewhatsmaller.

The University of Ioannina survey, presented data from three major Greekcities, as discussed previously. According to their data, Athenian high-school

0

2

4

6

8

10

12

14

16

18

20

1984 1993 1998

%Athens

Thessaloniki

Others urban areas

Semi-urban/rural areas

29

students presented the highest overall use (10.7%), but students fromIoannina were very close (9.1%), unlike students from Patras who presentedhalf the Athenian percentage (5.4%) (Figure 5). The same pattern wasobserved in occasional and regular use.

Figure 5: Use of psychotropic substances by high-school studentsin three major Greek cities

SOURCE: Dimitriou 2000

G e n e r a l p o p u l a t i o n d a t a

Geographical distributions of use between 1984 and 1998 are presented inFigure 6 (Kokkevi and Stefanis 1991; Kokkevi and Stefanis 1994).

Figure 6: Geographical distribution of illicit drug use amongthe general population


10,7

5,4

9,1

6,4

3,9

5,24,3

1,5

3,9

0

2

4

6

8

10

12

Athens Patras Ioannina

%

Overall use

Occassional use

Regular use

6,2

42,8 2,6

16,715,5

9,4 9,2

02

46

81012

1416

1820

Athens Thessaloniki Other urban areas Semi-urban/ruralareas

%

1984

1998

30

As seen in Figure 6, the small difference which existed between theprevalence rates of Athens and Thessaloniki in 1984 has almost disappearedin 1998. Other urban and rural areas show equally large increase in these 15years period.

Prevalence rates on different geographical regions in Greece are expected tocome out of an epidemiological survey, which the UMHRI conducted in 1999in collaboration with the co-ordinating unit OKANA. The sample wasrepresentative for each of the 27 prefectures where OKANA PreventionCentres function. The ESPAD protocol and questionnaires were used. Resultswill be available by the end of the year 2000.

D r u g u s e i n t h e G r e e k N a v y

The Bureau for Prevention and Mental Health of the Greek Navy conductedresearch on the Navy conscripts, aiming at investigating drug use, attitudesand associated psychopathology among them. According to the conscriptsself-reports, 30% had experience with drugs, one fourth of whom reportedregular use. Drug use was associated with depressive symptoms but not withage or educational level (Menoutis et al. 1999).

D r u g u s e i n t h e p r i s o n s

The first investigation of drug use in prison settings in Greece was conductedin 1995 in two surveys, one by OKANA an the other by the Department ofSociology of the National School of Public Health (NSPH).

The OKANA survey was conducted in two major Greek prisons, aiming atinvestigating the risk behaviours in imprisoned IVDUs and the prevalence ofinfectious diseases among them.

In 1995 the overall number of imprisoned individuals for drug offences inGreece was 1,890 (33,2% of all prisoners) (Malliori 2000). The study wasconducted in one prison in Athens (Korydallos) and one in Patras (Ag.Stefanos).

Of the 544 drug users who participated, 375 (68.9%) had injected drugs(IDUs) at some time (35% of whom had injected inside prison). Overall druguse in prison (intravenous or not) was reported by 53.7% of the participants(Malliori et al. 1998).

The demographic characteristics of the drug users inmates in the sample ofthis study are presented in Table 3.

31

Table 3: Demographic characteristics of drug users amongprison inmates in 1995

ALL DRUGUSERS(N=544)

IDUs(N=375)

NON-IDUs(N=169)

N % N % N %

Gender

Male 498 (91.5) 338 (90.1) 160 (94.7)

Female 46 (8.5) 37 (9.9) 9 (5.3)

Mean age (years) 36 35 38

Nationality

Greek 489 (90.1) 354 (94.7) 135 (79.9)

Other 54 (9.9) 20 (5.3) 34 (20.1)

Education

Never attended school 16 (2.9) 9 (2.4) 7 (4.1)

1 – 6 years 192 (35.4) 114 (30.5) 78 (46.2)

7 – 12 years 276 (50.8) 207 (55.3) 69 (40.8)

> 12 years 59 (10.9) 44 (11.8) 15 (8.9)SOURCE: Malliori et al. 1998.

Most of them were Greeks, especially those who reported intravenous druguse. A large percentage had completed secondary education. Their mean agewas 36 years.

The NSPH survey in prisons (Koulierakis et al. 2000) was conducted in 10Greek prisons on a sample of 861 male inmates. Two hundred and ninety(33.7%) reported drug use at sometime in their lives and 174 (20%) while inprison.

Data from the Treatment Demand Indicator are given for the PsychiatricHospital of Korydalos prison in Athens. It cannot be clarified wether self-reported drug use refers to use before or during imprisonment, because,although data are collected within the first month of imprisonment in theparticular prison, many inmates are transferred from other prisons. In 1999data are collected for 126 male imprisoned drug users, with mean age 34years. The main substance of use was heroin for the majority (62.7%),cannabis for 27% and cocaine for 6.3%.

It seems therefore that drug users continue using drugs while in prison, eventhough drug use is strictly forbidden in prison settings. Sharing needles isapparently very frequent, and is associated with length of imprisonment(Koulierakis et al. 2000).

32

2.2.4 Discussion

The sharp increase in illicit drug use, observed mainly after the first years ofthe nineties decade, as well as its consequences are discussed in theprevious chapter.

The economic growth and "europaisation" of Greece in the nineties affectedinevitably the role of women in society, resulting in their penetration intraditionally male domains and the adoption of new social roles, behavioursand attitudes, resembling those of men more and more. Although theirdevelopment is considered positive and has indeed improved women'sposition and quality of life, it bears social costs, one of which seems to besubstance use, a traditionally male behaviour in Greece. Nevertheless, stillmore men than women are regular users. In the past few years specialattention was given to women drug users in the therapeutic field but not so inthe research field. Studies focusing on women are still lacking.

The geographical distribution of drug use has also changed through the years.During the 80's drug use was concentrated in the largest metropolitan areas,Athens and Thessaloniki. In the ninenties, urban and, to a lesser extent, ruralareas seem to approach the largest cities in drug use prevalence.Nevertheless, Athens as the capital, continues to be at the top, offeringgreater opportunities for experimentation and recreational use. It also attractsregular and dependent users, as it combines availability and anonymity, and,for the most motivated ones, therapeutic services.

The observed difference in illicit drug use between 1998 school populationsurveys and the ESPAD survey, although not statistically significant, shouldrather be attributed to methodological reasons as all other indicators point atthe directions of drug use increase. A subsequent epidemiological survey willclarify the issue.

Social groups, such as army conscripts and prisoners are largely "terraingognita" in Greece as far as drug research is concerned. The highprevalence among conscripts in the survey of the Navy is an indication of thedimensions of the problem and shows the need for further investigation.

2.3 Problem drug use

Problematic drug use estimates are still lacking in Greece. The main problemis the strict enforcement of the law for the protection of personal data inGreece. The only possible source are the police records, which will possiblybe available when the implementation of their new data base will havefinished.

Data from indirect indicators of problematic prevalence show that the problemof drug dependence is increasing in Greece.

33

According to data from the Treatment Demand Indicator, the number ofapplications for therapy has doubled the last 4 years, both in the drug free andin the substitution programmes, while at the same time the mean age ofapplicants is lowered by 2 years (see section 3.1 for details).

The number of drug related deaths, which presented stability between 1996and 1998, increased sharply in 1999. Increase is also apparent in the numberof arrests for drug related offences.

The patterns of problematic use do not seem to have changed significantlyover the last few years. There is an increase in cocaine use as a secondarysubstance, the main one being still heroin. There is also a shift, for heroinusers from injecting to alternative modes of heroin administration, such assniffing or smoking.

Data from low threshold and street work services (Help Centre of OKANA)show an increased number of new "clients" who either contacted the servicesthemselves or were approached in the framework of street work.

2.3.1 Adolescents and young adults drug users

The profile of Greek adolescent drug users can be drawn by data of theTherapeutic Programme for Adolescent Drug Users and their Families"STROFI", a unit belonging to the therapeutic centre KETHEA and isaddressed to adolescent and young adults occasional and dependent users."STROFI" also offers counselling to adolescent users who are arrested fordrug related offences.

The data presented in Figure 7 refer to the adolescents and young adults whorequested treatment from "STROFI" in 1998 (N=419) and 1999 (N=450) andthey were collected through personal interview (STROFI 1998; STROFI1999).

34

Figure 7: Characteristics of adolescents and young adults drug usersrequesting treatment at "STROFI" in 1998-1999

SOURCE: STROFI, 1998, 1999.

The demographic characteristics of adolescent and young adults users haveslightly changed in the last two years; although the majority are still boys,aged around 18 years, smaller percentage live with families, whereas thepercentage of school drop-outs has slightly increased. Concerning the mainsubstance of abuse, a slight shift from cannabis to heroin is observed.

2.3.2 Risk behaviours

Risk behaviours among IVDUs, mainly needle sharing, is being studied inGreece since 1991.

�n 1991, 75% of the IVDus in Greece reported needle sharing (Kokkevi et al.1991). In the following year, 1992, the same percentage (75.7%) was reported(Kokkevi et al. 1992), while from another study it was found that 41.8% ofIVDUs always clean their equipment before sharing (Malliori et al. 1992)(Table 4).

11,6

35,3

48,9

42,9

15,9

50,9

90,2

18

79,6

11,5

38,9

53,2

43,7

15,8

48,2

94,5

18,1

79,5

0 20 40 60 80 100

tranquilisers

heroin

cannabis

Unemployed

Mean age of leaving school

Dropped-out of school

Living with family

Mean age

Boys

%

Main substance of abuse

1998

1999

35

�able 4: Needle sharing among Greek IVDUs as reported indifferent studies in 1991-1993

19911 19922,3 19934

% % %

Needle sharing 75 75.72 49.3(in the last6 months)

Cleaning equipment beforesharing 41.83

Using condoms 21.4 21.42 22.5

1 Kokkevi et al. 19912 Kokkevi et al. 19923 Malliori et al. 19924 Malliori et al. 1993

In the beginning of the 90s risk behaviours seemed to remain at high levels. Itwas in the second part of the 90s decade, that the effect of preventivestrategies became visible, as seen in a study conducted in 1998.

That study investigated changes in the Greek IVDUs between 1993 and 1998and was conducted on a sample of IVDUs who contacted the AIDS ReferenceCentre of the National School of Public Health in these two reference periods(Kornarou et al. 1999). Their main findings are summarised in Table 5.Needle sharing at least once in lifetime was decreased from 72% in 1993 to55.9% in 1998, while sharing in the last 6 months remained at the same level.More users seemed to try to clean their equipment (74% in 1998 compared to33% in 1993), and twice as many users in 1998 (18.9%), compared to 1993(10%) managed to sterilise them properly. Moreover, increased percentagesof users seemed to use condoms in their sexual relationships with occasionalpartners. The authors conclude that needle sharing is still highly prevalentamong intravenous drug users, while they seem to be more careful in theirsexual behaviour.

36

Table 5: Changes in the risk behaviours of Greek intravenousdrug users between 1993 and 1998

1993(N=200)

1998(N=243)

% %

Needle sharing at least once inlifetime 72 55.9

Needle sharing in the last 6months 39.4 38.6

Cleaning of the equipment 33 74

Proper sterilisation 10 18.9

Condom use (with occasionalpartner 22.1 64.5

SOURCE: Kornarou et al. 1999

Data from "STROFI" on the risk behaviours among adolescents and youngadults are summarised in Figure 8. Injecting and sharing needles wasreported by larger percentages of girls than by boys. Girls seem to startinjecting at an earlier age than boys. Both genders reported frequent use ofcondoms at high percentages.

In the prison settings, in 1995 (Malliori et al. 1998), 67% of the inmates whoreported injecting in prison admitted needle sharing, while in 1996 (Koulierakiset al. 2000), 83.4% of those admitted to have injected drugs in prisonconfessed that they shared needles.

Equipment sharing among the Greek drug users presents high prevalence,although syringes are freely purchased in Greece and at a very low price(0.15 EUROs). From recent qualitative data collected by the Focal Point, mostpharmacists, wanting to contribute to the reduction of needle sharing, seem tobe quite willing to sell syringes to users, sometimes even giving them free ofcharge.

Nevertheless, even if there is no major problem in syringe obtaining, reportsfrom the users themselves present needle sharing as part of their sub-culture,as an almost ritualistic behaviour, through which they are supposed to provetheir trust to each other and ascertain their belonging to the group (Kokkevi etal. 1991).

Data from interviews at therapeutic settings indicate that, in Greece, sharing ismostly limited among relatives, siblings and sexual partners or spouses.

In the prisons where obtaining syringes is extremely difficult, the proportion ofusers who share is increased.

37

Figure 8: Risk behaviours among adolescent and young adults drug users

Needle sharing

Injecting

Condom use (with occasional partners)

SOURCE: STROFI, 1999, 2000

45,4

57,8

47,2

58,2

0

10

20

30

40

50

60

70

Boys Girls

%

1998

1999

37,8

51,2

40,2

59,8

0

10

20

30

40

50

60

70

Boys Girls

%

1998

1999

64,2 62,7

76,5

55,4

0

10

20

30

40

50

60

70

80

90

Boys Girls

%

1998

1999

38

2.3.3 Dropping-out of treatment

The first study carried out in Greece on drop-out rates and associated factorswas recently published by one of the major drug-free treatment agencies inGreece, the Centre of Therapy for Dependent Individuals (KETHEA)(Poulopoulos and Tsiboukli 1999).

The sample consisted of 299 dependent individuals admitted to treatment in1995-96. Data were collected by personal interview based on the TreatmentDemand Protocol.

According to their findings:

• The annual drop-out rate was 73.6%.

• The majority of clients who dropped-out, did so in the first 30 days oftreatment, while those who remained for at least 3 months were more likelyto complete treatment.

• Past treatment experience increased the risk of dropping-out

• Clients over 30 years old were at higher risk for dropping-out compared totheir younger counterparts

• Current injectors (injecting in the last 30 days) were also more likely todrop-out than those who were not injecting in the month prior to enteringtreatment.

3. HEALTH CONSEQUENCES

3.1 Drug treatment demand

The implementation of the Drug Treatment Demand indicator in Greece hasbeen discussed in details in all previous National reports. Twelve treatmentservices available in Greece, including the Methadone SubstitutionProgramme provide data to the Focal Point at the end of each month.Individual data are provided using an anonymous identification code, so thatthey can be cleared from double-entries at the Focal Point.

In 1999 a new addition was made to the collaborating treatment services, theAlternative Therapeutic Programme (ARGO) of the Psychiatric Hospital ofThessaloniki.

A total of 1,096 clients from all the services participating to the reportingsystem of the drug treatment demand indicator, requested treatment in 1999,919 from the drug free programmes and 177 were admitted in the methadonesubstitution programme. (The methadone substitution programmes includedata for admissions and not for treatment demands).

39

3.1.1 Summary of the characteristics of all clients who requested treatmentin 1999

S o c i o d e m o g r a p h i c c h a r a c t e r i s t i c s

• The majority of users were men; the ratio of men to women was 5:1

• The mean age of users was 28 years old

• Four fifths of them lived in Athens and Thessaloniki

• More than half of them had not completed secondary education. Womenhad higher educational level than men.

• Half of them were unemployed, while 1/4 had a full time job.

• The majority of them lived with their parents

• One tenth of them lived with other dependants

T r e a t m e n t b a c k g r o u n d a n d r e f e r r a l s

• Half of them had never been previously treated.

• More than half of them stated as source of referral themselves or theirfriends, while one third of users were persuaded by their family

P a t t e r n s o f u s e

• Heroine and other opiates were the primary substances of use

• The main route of administration of heroine was injection, while thepercentage of those who smoked or inhaled had increased

• Half of them were polydrug users

• The majority had started their drug career with cannabis

• The mean initiation age for heroine use was 21 years, while for cannabiswas 16 years.

H i g h r i s k b e h a v i o u r

• More than 2/3 of users injected currently (last month) and this proportionwas increasing according to age.

• The mean age of initiation of injecting was 21 years.

• One third of current injectors shared needles, more women than men.

I n f e c t i o u s d i s e a s e s

• One third of them had never been tested for HIV or hepatitis.

• Half of those who have been tested were found positive for hepatitis,mainly C, while 2.2% of those tested were found HIV positive.

40

3.1.2 Characteristics of new clients in 1999


In 1999, 608 new clients requested treatment, a number which constitutes 55.6% ofall users who requested treatment.

Of these 46.5% stated as source of referral themselves or their friends, while35.7% of new clients were referred by their family.

• The majority were males (82.8%).

• Half of them (51.1%) are between 20-29 years old, while one third wereover 30 and 17.4% were adolescents (younger than 19 years old). Theirmean age was 26.6 years.

• Almost half of them were unemployed (48.8%), only one fourth had a fulltime job. Most (68.7%) had completed secondary education.

• Most of them (73.9%) lived with their parental families (Figure 9).

Figure 9. Sociodemographic characteristics of new clients

SOURCE: Greek REITOX Focal Point, 2000

3,5

14,5

8,2

73,9

2,2

10

48,8

13,9

25

31,5

51,1

17,4

17,2

82,8

0 20 40 60 80 100

Other

Spouse/partner

Alone/with friends

Parental family

Other

Students

Unemployed

Part time job

Full time job

30 + years old

20 - 29 years old

- 19 years old

Women

Men

%

41

Table 6: Characteristics of users starting treatment

All Treatments First Treatment

YEAR: 1999 M F T M F T

Treatment cases/demands (Number) 918 175 1093 501 104 605

Sex distr. (%) Male / (%) Female 84% 16% 100% 82.8% 17.2% 100%

Mean age (Years) 29 27 28 27 24.7 26.6

Age distribution <15 0.5 0.6 0.5 0.8 1.0 0.8

15-19 10.1 18.3 11.4 14.8 26.0 16.6

20-24 25.6 26.3 25.7 31.1 31.7 31.4

25-29 20.7 20.0 20.6 20.6 15.4 19.7

30-34 20.7 18.9 20.4 15.6 14.4 15.3

35-39 12.2 9.1 11.7 9.0 6.7 8.6

40-44 7.5 5.7 7.2 6.4 3.8 5.9

45-49 1.9 0.6 1.6 1.2 1.0 1.2

50-54 0.5 0.6 0.5 0.2 0 0.2

55-59 0.2 0 0.2 0.4 0 0.3

60-64 0 0 0 0.0 0 0

≥ 65 0 0 0 0.0 0 0

Number of cases with missinginformation on age

0 0 0 0 0 0

Injection behaviour − − − − − −

Currently injecting any drug (%) 70.6 52.0 67.7 64.5 47.1 61.6

Ever injected any drug but notcurrently (%)

12.6 22.3 14.1 10.4 18.3 11.8

Ever injected any drug (%) 83.2 74.3 82.0 74.9 65.4 73.4

IV route of ad. Main drug (%) 72.8 54.0 69.8 60.9 40.4 57.4

Main drug (%) – (% IV use) dr. % IV % dr. % IV % dr. % IV % dr. % IV % dr. % IV % dr. % IV %

Opiates (total) 90.1 74.6 86.4 58.3 89.5 72.0 85.8 70.2 79.8 56.0 84.9 71.8

Heroin 89.3 75.1 84.6 58.3 88.6 72.7 85 71.0 79.8 56.0 84.2 72.2

Methadone (any) 0.2 0 0.6 0 0.3 0 0 0 0 0 0 0

Other opiates 0.6 16.7 1.2 0 0.6 14.3 0.8 25.0 0 0 0.7 33.3

Cocaine (total) 1.7 18.7 1.1 0 1.6 16.7 2.4 8.3 1.9 0 2.3 7.1

Cocaine CIH 0 0 0 0 0 0 0 0 0 0 0 0

Crack 0.98 0 0 0 0.9 0 1.6 0 0 0 1.3 0

Stimulants (total) 0.1 0 0 0 0.1 0 0.2 0 0 0 0.2 0

Amphetamines 0 0 0 0 0 0 0 0 0 0 0 0

MDMA and derivates 0.1 0 0 0 0.1 0 0.2 0 0 0 0.2 0

Other stimulants 0 0 0 0 0 0 0 0 0 0 0 0

Hypnot. and sedat. (total) 0.98 0 2.3 0 1.2 0 1.4 0 1.9 0 1.6 0

Barbiturates 0 0 0 0 0 0 0 0 0 0 0 0

Benzidiazepines 0.98 0 1.7 0 1.1 0 1.4 0 1.9 0 1.6 0

Others 0 0 0.6 0 0.1 0 0 0 0 0 0 0

Hallucinogens (total) 0 0 0 0 0 0 0 0 0 0 0 0

LSD 0 0 0 0 0 0 0 0 0 0 0 0

Others 0 0 0 0 0 0 0 0 0 0 0 0

Volatile inhalants (total) 0 0 0 0 0 0 0 0 0 0 0 0

Cannabis (total) 6.3 0 10.3 0 6.9 0 9.6 0 16.3 0 10.7 0

Other substance (total) 0.7 14.3 0 0 0.7 14.3 0.6 33.3 0 0 0.6 33.3


42


• The vast majority of new clients (84.9%) were opiate users (mainly heroin),while cannabis was the primary substance of use for 10.7% of them,cocaine and crack (2.3%), pills (hypnotics and sedatives) (1.6%).

• Injection was the most common route of administration for heroin andother opiates (71.8%) (Table 6).

The sociodemographic characteristics and patterns of use of new clients didnot differ significantly to those of all clients, which probably implies that theprofile of dependent individuals remains practically the same.

3.1.3 Different client profiles in different types of treatment

Treatment demand data can be categorised in those deriving from: a)drug-free programmes and the methadone substitution programme, b) nonresidential and residential programmes.

Table 7: Number of individuals seeking treatment in differenttypes of treatment during 1999

N % N %

Drug-free 919 83.9 Non residential 501 45.7

Substitution * 177 16.1 Residential 595 54.3

Total 1,096 100 1,096 100

* The methadone substitution programme includes data for admissions, notor treatment demands.


Client profiles in drug-free and methadone substitution programmes during1999


• The proportion of women is higher in the substitution programmecompared to the drug-free programmes. Mothers and pregnant womenhave priority to enter the methadone programme. The ratio of men towomen for the substitution programme was 3:1, while for drug-freeprogrammes was 6:1.

• Age (older than 22) is one of the criteria for admission to the methadoneprogramme, and older (aged 35 and over) applicants are preferred.Therefore, clients from drug-free programmes were younger, the majority(53.4%) between 20-29 years old, while the percentage of clients from the

43

substitution programme who were over 30 years old was much higher(89.8%) (Figure 10).

Figure 10: Age distribution of clients in drug-free and substitution programmes


• More clients from drug-free programmes had a full time job than theircounterparts in the substitution programme (24% and 15.3%, respectively),and more clients from the substitution programme were unemployed(66.7% in the substitution programme and 50.4% in the drug-free ones)(Figure 11).

Figure 11: Labour status of clients in drug-free and substitution programmes


14,3

53,4

32,3

0

10,2

89,8

0

10

20

30

40

50

60

70

80

90

100

- 19 years old 20 - 29 years old 30+ years old

%

Drug-free

Substitution

24

16,8

50,4

7,11,7

15,3 14,7

66,7

03,4

0

10

20

30

40

50

60

70

80

Full time job Part time job Unemployed Students Other

%

Drug-free

Substitution

44

• The majority of clients from drug-free programmes (74.3%) lived with theirparental family. Fewer clients from the substitution programme (44.1%)lived with their family and 27.6% lived with their spouse or partner, whilemost of them (76.6%) stated as source of referral themselves or theirfriends.


• Intravenous heroin use that has led to daily use is another criterion toenter substitution treatment. Therefore, all clients from the substitutionprogramme were heroin users and most of them (76.3%) were currentinjectors. Fewer clients from drug-free programmes were heroin users(86.4%) and current injectors (66.1%), while the percentage of clients fromthis type of treatment who reported cannabis as primary substance of usewas quite low (8.3%).

• Half of the clients from both of types of centres were polydrug users(55.1% in drug-free and 54.8% in the methadone programme).

• More clients from drug-free programmes (42.1%) shared needlescompared to those from the methadone ones (23.3%); most were women.

• In the methadone substitution programme clients are required to be testedfor hepatitis and HIV. Not all drug-free programmes have this requirement.Thus, more clients from drug-free programmes had not been tested forhepatitis (39%) or HIV (40,3%), compared to those from the substitutionones, 11.3% for hepatitis and 12.5% for HIV.

Clients from the drug-free programmes and from the substitution one are twodifferent types of population. Their differences are mainly attributed to thestrict and very specific criteria that the substitution programme uses (age,drug career, high risk behaviour). Clients from the drug free programmes areyounger, live with their parental family, report other drugs as main substancesof abuse apart from heroin, share needles more frequently and a largenumber of them haven’t been tested for hepatitis or HIV. Respectively, clientsfrom the substitution programme are older, live with their spouse or partner,their only substance of abuse is heroin, and few of them (around 10%) havenot been tested for hepatitis or HIV. Half of the clients from both types ofprogrammes are polydrug users.

Client profiles in non residential and residential programmes during 1999

Most of the individuals (54.3%) demanded treatment from residential units,while 45.7% from non residential units.


• The ratio of men to women in non residential units was 4:1, while inresidential units was 7:1. The proportion of women is higher in nonresidential units, where the methadone substitution programme is included.

45

• Clients from non residential units were older, 52.9% were over 30 year old,while clients from residential units were younger, 54.5% were between 20and 29 years old (Figure 12).

Figure 12: Age distribution of clients in non residential and residentialprogrammes


• Half of the clients from both types of centres were unemployed, while moreclients (26.1%) from non residential units had full time job, compared toclients from residential units (19.5%) (Figure 13).

Figure 13: Labour status of clients in non residential and residentialprogrammes


13,4

54,5

32,1

10,2

36,9

52,9

0

10

20

30

40

50

60

70

- 19 years old 20 - 29 years old 30+ years old

%

in-patient

out-patient

19,5 19,5

53,9

6,22,4

26,1

13,1

52,2

5,61,6

0

10

20

30

40

50

60


%

in-patient

out-patient

46

• Most clients from non residential programmes (63.7%) lived with theirparental family and 17.8% with their spouse or partner, while the majority ofthose (74.3%) from residential ones lived also with their parental family.Although they lived with their families most of the clients from both types oftreatment stated as source of referral themselves or their friends.


• More clients from residential units were opiate users (92.1%), currentinjectors (75.5%) and shared needles (75.5%) than clients from nonresidential ones (86.4%, 58.5% and 58.5% respectively). On the otherhand, more clients from non residential units reported cannabis as primarysubstance (9.2%) and cocaine (2.4%) than those from residential (5.1%and 1%) respectively (Figure 14).

Figure 14: Primary substance used by clients in non residentialand residential programmes


• Most of clients from both types of centres were polydrug users (44.9% innon residential and 63.5% in residential programmes), although, moreclients from non residential centres (17.8%) reported using only onesubstance than those from residential ones (9.2%) (Figure 15).

92,1

5,11 1 0,2 0,7

86,4

9,22,4 1,4 0 0,6

0

10

20

30

40

50

60

70

80

90

100

Heroin andother opiates

Cannabis Cocaine Sedatives Ectasy Other

%

in-patient

out-patient

47

Figure 15: Number of substances used by clients in non residentialand residential programmes


Almost one third of clients from both types of centres have not been tested forhepatitis or HIV.

Clients from non residential and residential units are two different types ofpopulation and their profile is not always determined or influenced by theinclusion of drug-free or substitution programme. Clients from non residentialunits are older and have a higher proportion of women compared to clientsfrom residential ones. Regarding patterns of use, less clients are heroin users,current injectors and they share needles less frequently compared to thosefrom residential ones. Finally, most clients from all types of treatment arepolydrug users, although there is a percentage 17.8% of clients from nonresidential units who use only one substance.

3.1.4 Treatment demand for cannabis

A small percentage (6.9%) of users stating cannabis as primary substancedemanded treatment for cannabis use.


• The majority of cannabis users were young men, below 30 years old.Specifically, one third of them (34.2%) were younger than 20 years old,while the respective percentage for heroin users was 9.9%.

• One third of them (28.4%) are students and almost half of them (48%)were high school graduates. Comparing to opiate users, half of them areunemployed and one third (32.8%) were high school graduates (Figure 16).

• The majority of cannabis users (86.7%) requested treatment for the firsttime, while almost half of opiate users (47.4%) have been treated before.

9,2

27,3

63,5

17,8

37,3

44,9

0

10

20

30

40

50

60

70

One substance Two substances Three substances

%

in-patient

out-patient

48

• Most of cannabis users (82.7%) lived with their parental family and half ofthem (55.3%) were persuaded by their family to ask for treatment. Althoughthe majority of opiate users (67.9%) lived with their parental family and14.1% with their spouse or partner, most of them (61%) have stated assource of referral themselves or friends.

Figure 16: Sociodemographic characteristics of cannabis users



• The mean initiation age for those who demanded treatment for cannabiswas 17 years, while for heroin it was 21 years.

• Only a small number of them (5.3%) were current injectors, in contrast toopiate users were injectors were the majority (74.4%), in the last 30 days.

• Half of the cannabis users (51.3%) took only one substance, while morethan half of opiate ones (58%) were polydrug users (Figure 17).

1,3

5,3

10,6

82,7

5,4

28,4

33,8

12,2

20,3

18,4

47,4

34,2

23,7

76,3

0 20 40 60 80 100

Other

Spouse/partner

Alone/with friends

Parental family

Other

Students

Unemployed

Part time job

Full time job

30 + years old

20 - 29 years old

- 19 years old

Women

Men

%

49

•

Figure 17: Number of substances used by cannabis and opiate users


• The majority of cannabis users (over 75%) have not been tested for HIV orhepatitis, while the one third of opiate users (almost 30%) haven’t beentested for these infectious diseases.

Cannabis users have different characteristics from opiate ones. They areyoung, one third of them are students, they are staying with their parentalfamily and the majority of them requested treatment for the first time. Theirpatterns of use differ, as well. The majority were not current injectors and theyhad not been tested for hepatitis or HIV, and half of them use only onesubstance. On the other hand, opiate users are older, half of them areunemployed and they had been treated before. The majority of them lived withtheir parental family, while one sixth live with their spouse or partner. Most ofthem are current injectors and polydrug users, while one third had not beentested for hepatitis or HIV.

3.1.5 Comparisons of all clients characteristics between 1996-1999

S a m p l e s o f d r u g u s e r s

After 5 years of implementation of the Treatment Demand Indicator in Greece,it was considered worthwhile to examine the extent to which the profile of theusers requesting treatment has changed.

The first two units of the methadone substitution programme startedfunctioning in 1995, when the selection of the first clients was made. In thesubsequent years (1996 and 1997) new admissions were made only on gaps

51,3

27,6

21,1

10,2

31,8

58

0

10

20

30

40

50

60

70


%

Cannabis users

opiate users

50

caused by drop-outs. In 1998 the methadone substitution programmeadmitted again a large number of clients for its two new units. Thus theproportional representation of the substitution data in the overall number ofclients in the indicator in these five years is as follows: 34% in 1995, 10.1% in1996, 4.7% in 1997, 43% in 1998 and 16.1% in 1999. Because of this, 1999data for all treatment units are compared to the 1996 ones, as these two setsof data present the greatest homogeneity (Table 8).

Table 8: Number of individuals demanding treatment in 1996 and 1999

1996 % 1999 %

Drug-free programmes 491 89.9 919 83.9

Substitution programme * 55 10.1 177 16.1

Total 546 100 1,096 100

* The methadone substitution programme includes data for admissions, not fortreatment demands.


• In 1999 twice as many users demanded treatment than 1996 (1,096 and546, respectively). The increase is apparent in both types of treatment

The sociodemographic characteristics of the two populations are thefollowing:

• The number of individuals demanding treatment in drug-free programmeshas increased (491 in 1996 and 919 in 1999). Alternative TherapeuticProgramme “ARGO”, a drug free programme was added in the reportingsystem in 1999.

• The number of individuals admitted for treatment in substitutionprogrammeshas also increased (55 in 1996 and 177 in 1999). In 1998 twonew Methadone Substitution Programmes were added to the two existingones.

P r e s e n t a t i o n o f c o m p a r a t i v e d a t a

The sociodemographic characteristics of the two samples of individualsseeking treatment are the following:

Decrease is observed in:

• The percentage of men seeking treatment (88.6% in 1996 and 84% in1999).

51

• The average age of clients (the average age was 30 in 1996, 28.3 in1999), because the percentage of adolescents seeking treatment isincreasing (3,8% in 1996 and 7,8% in 1999), while the percentage ofindividuals over 30 years old is decreasing (50.5% in 1996 and 41.6% in1999).

• The percentage of elementary graduate (32.1% in 1996 and 24.9% in1999)

• The percentage of drug users who have a full time job (30.6% in 1996 and22.6% in 1999), while the percentage of students seeking treatment isincreasing (1.9% in 1996 and 5.9% in 1999), following the decrease ofaverage age. The majority of drug users is unemployed (52.4% in 1996 and53.1% in 1999) (Figure 18).

Figure 18: Labour status of clients demanding treatment in 1996 and 1999


• Injection of heroin as the common route of administration (83.1% in 1996and 78% in 1999), while the percentage of those who smoke or inhaleheroin is increasing (5.9% in 1996 and 9.2% in 1999). This might be anoutcome of the implementation of “safe use” programmes.

Increase is observed in:

• The percentage of drug users who live with their parents (62.4% in 1996and 69.4% in 1999) (Figure 19).

• the percentage of dependants who were induced by their family to ask fortreatment (12.1% in 1996 and 27.5% in 1999).

• Polydrug use (35.8% in 1996 and 55% in 1999). According to qualitativedata, the increase of polydrug use is caused by the increase of availabilityof other substances. Heroin users experiment with various substances to

30,6

12,7

52,4

1,9 2,4

22,6

16,5

53,1

5,92

0

10

20

30

40

50

60


%

1996

1999

52

enhance heroin’s effect or use substances which antagonise each other.Cannabis is the primary substance for 7% of users.

Figure 19: Living status of clients demanding treatment in 1996 and 1999


• Secondary substances like cannabis (49.8% in 1996 and 60% in 1999),pills (28.2% in 1996 and 52.5% in 1999) and cocaine (10.6% in 1996 and14.8% in 1999), while alcohol use is decreasing (6.8% in 1996 and 2.5% in1999).

• Cannabis as initiation substance of use (68.7% in 1996 and 75.2% in1999), while average initiation age of substance use (17 years old in 1996and 16 years old in 1999) and average age of first injecting use (22 yearsold in 1996 and 21 years old in 1999) is decreasing.

• The percentage of current needle sharing (31.1% in 1996 and 38.8% in1999). According to qualitative data, heroin users, usually, share needleswith their partners trying to confirm the close binds between them.

3.2 Drug related mortality

The Greek Focal Point collects on a yearly basis data on deaths caused byacute intoxication (overdose or synergic activity of different drugs). The ThirdSection of Drugs of the Public Security Directory in the Ministry of PublicOrder is responsible for the collection of data on drug related deaths, whichare published in the Annual Report of the Central Anti-drug Co-ordinating Unit(SODN-EMP). These data are based on the death certificates issued by theforensic laboratories in cases of sudden deaths or after request of the lawenforcement authorities for forensic investigation when involvement of drugs

62,4

9,2

18

10,3

69,4

11,6 13,2

5,8

0

10

20

30

40

50

60

70

80

Parental family Alone/with friends Spouse/partner Other

%

1996

1999

53

in a death case is validly suspected. The Third Section of Drugs maintainsthat the national coverage of these data is 97%.

The increase in drug related deaths in Greece is particularly obvious in thelast 5 years (Figure 20). In 1994 the number of deaths increased by almost90% compared to 1993. In the period between 1997-1998 the rate of increaseshowed stabilisation, at around 5% until 1999, when the number of deathsreported was 264, number increased by 8% compared to 1998.

Figure 20: Drug related deaths (1985-1999)

SOURCE: Central Antidrug Coordinating Unit, 2000

The demographic characteristics of drug users who died from acuteintoxication in the last 5 years are presented on Table 9. As observed, themajority were:

• Men, aged between 21-30 years

• Athens prefecture residents

• Single

• Secondary education graduates

• Unemployed

Heroin was responsible for the majority of cases.

The main factors contributing to the increase in drug related deaths are theincrease in drug use observed in Greece and the ageing population of drugusers which implies deterioration in their health. The head of the Help Centreof OKANA remarks that death risk is also increased among relapsed IVDUs,as it has been observed that they use purer heroin and often larger doseswhen they restart use after having undergone detoxification. Polydrug use

1028

56 6272 66 71 79 78

146

176

222 232245

265

0

50

100

150

200

250

300

350

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

N

54

and especially the new substances used often result in dangerous mixtures ofsubstances.

Table 9: Characteristics of drug related death cases in 1995-1999

YEARS OF REFERENCE

1995 1996 1997 1998 1999

Certified deaths 176 222 232 245 265

Gender

Males 162 202 209 216 245 Females 14 20 23 29 20

Age

< 20 years old 7 14 24 33 47

21–30 years old 90 98 102 112 122 > 31 years old 79 110 106 100 96

Geographical Area

Athens Prefecture 136 166 166 170 185

Thessaloniki Prefecture 18 25 38 39 31 Other 22 31 28 36 49

Marital Status

Single 157 184 96 227 245

Married 15 32 8 16 16 Divorced 4 6 1 2 4

Educational Level

Primary education 73 78 36 87 65

Secondary education 30 106 66 143 169 Higher education 6 4 2 3 3 Unknown 66 34 1 12 28

Uneducated 1

Profession

Unemployed 99 144 73 175 197 Workers 29 21 15 31 18

Private employees 20 9 6 14 11 Musicians 3 2

Sailors 4 7 1 1

Others 16 35 8 21 31 Prostitutes 4 1 1 1 Civil servants 1

Journalists

Scholars 3 1 4 6

Type of drug

Heroin 157 213 222 243 263

Morphine 3 1

Psychotropic drugs 13 7 6 1 1 Cocaine 1 3 1 1

Cannabis-Alcohol 2 1 1

SOURCE: Central Anti-drug Coordinative Unit, 2000

55

3.3 Drug related infectious diseases

3.3.1 HIV/AIDS

In Greece, surveillance data for drug related infectious diseases exist only onHIV/AIDS; these data derive from the surveillance of the Centre for theControl of AIDS and STDs (KEEL) of the Ministry of Health.

AIDS prevalence among drug users remains low.

For further details on AIDS, see Chapter 14. Infectious diseases.

3.3.2 Hepatitis B and C

The Greek Focal Point, in 2000, has intensified the efforts to collect data onthe prevalence of Hepatitis B and C among drug users. Seventeen sources ofinformation have been identified so far, out of which 13 have already givendata for 1999, which are included in the Standard Epidemiological Tables2000, along with data from special studies. These data are given from eachsource in aggregated form and have not been checked for double entries;therefore they are presented separately. The Focal Point has already madecontacts with sources that offer test results on the issue of individual datacollection, using an anonymous code. In this way it is hoped that data couldbe presented in unified form for the next year.

The sources of information identified are presented in Table 10.

Table 10: Sources and nature of information on Hepatitis B and C andstatus of collaboration with the Greek FP in 2000

SOURCE HIV – HBV -HCV

Offered data in2000

Will offer in2001

• Nine treatment programmes

Five drug-free programmes

Four units of the methadonesubstitution programme

ü

ü

ü

2 2

• Two public laboratories ü ü

• Needle-exchange programme ü Not analysed

• Prisons ü ü

• Two special programmes forwomen ü 1

• Self-reported data – TDI ü ü ü

• Centre for the control of AIDS andSTDs HIV ü ü

• 3 special studies ü ü

56

According to the test results performed in 1999, hepatitis B prevalence is quitelow (lower than 10%), while hepatitis C ranges between 60-90% amongGreek drug users.

Under-reporting is obvious in self-reported data.

3.3.3 Tuberculosis

Data on Mantoux test results are offered from the two methadone substitutionunits in Thessaloniki: 40% of the clients were found Mantoux positive in 1999,all males, the majority (68%) aged over 35 years old.

For further details on hepatitis see also Chapter 14. Infectious diseases.

3.4 Other drug related morbidity

3.4.1 Psychiatric co-morbidity

Several studies on psychiatric co-morbidity have been conducted in the last 5-6 years in Greece. They mainly investigated the existence of personalitydisorders and suicide ideation in drug dependent individuals.

P e r s o n a l i t y d i s o r d e r s a m o n g u s e r s i n t r e a t m e n t

Sample Ø 226 drug dependent clients in 3 therapeuticprogrammes

Data collection Ø psychiatric assessment. Diagnostic instruments used:SCL-90, EuropASI, Composite International DiagnosticInterview (CIDI), Structured Clinical Interview for DSM-IV Axis I Personality Disorders (SCID-II)

Main findings Ø 60% of the subjects were diagnosed for at least onepersonality disorder (PD), most (34%) for antisocial PD

Ø Subjects with PD showed, during pre-treatmentassessment, higher level of psychopathology, comparedto users without PD.

Ø Logistic regression analysis showed only PD existenceas a significant risk factor for dropping-out of treatment.

Reference: Kokkevi et al. 1998b

57

P e r s o n a l i t y d i s o r d e r s a m o n g u s e r s i n t r e a t m e n t a n d i np r i s o n

Sample Ø 176 drug users in treatment and prison

Data collection Ø Psychiatric assessment. Diagnostic instruments used:Diagnostic Instrument Schedule (DIS)

Main findings Ø DSM-III disorders: antisocial (69.3%), anxiety (31.8%),affective (25%),

Ø Antisocial personality disorder preceded drugdependence

Reference: Kokkevi and Stefanis 1995

S o c i a l p h o b i a a n d d e p r e s s i v e s y m p t o m a t o l o g y

Sample Ø 48 drug users requesting treatment

Data collection Ø Psychiatric assessment. Diagnostic instruments used:CES-D for depression (Centre for EpidemiologicalStudies – Depression), CIDI for social phobia

Main findings Ø Thirty seven users (77.1%) presented depressivesymptomatology (SEC-D>-16)

Ø Six users (12.5%) presented symptoms of social phobia

Reference: Liappas et al.1998

S u i c i d e a t t e m p t s a m o n g d r u g d e p e n d e n t s

Sample Ø 25 (16 men and 9 women) drug dependent individualssuicide attempters.

Ø Nineteen (76%) were heroin dependent, 6 (24%) weredependent on benzodiazepines and anticholinergics.

Ø Age range: 15-45 years old. Mean age: 24 yearsData collection Ø Personal interview.

Main findings Ø Psychiatric assessment (DSM-III R)

Ø The majority (56%) were diagnosed as having antisocialpersonality disorder

Ø 20% major depression

Ø 16% anxiety disorder

Ø 8% psychotic disorderØ Reasons for the attempt (self-reported)

Ø 68% problems in interpersonal relationships

Ø 24% financial problems

Ø 8% auditory hallucinations

Reference: Pertessi et al. 1998

58

S e l f - d e s t r u c t i v e b e h a v i o u r , s u i c i d e a t t e m p t s a n d c o c a i n eu s e

Sample Ø 231 drug users in treatment

Data collection Ø Psychiatric assessment: DSM-III-R, CES-D

Main findings Ø Cocaine users presented higher levels of depression,compared to users of other drugs

Ø Suicide attempts were more prevalent in cocaine users thanin other drugs users

Reference: Liappas et al.1996

S u i c i d a l b e h a v i o u r a n d c h r o n i c h e r o i n u s e

Sample Ø 458 users in substitution treatment

Data collection Ø Psychiatric interview

Main findings Ø The majority (52%) presented suicidal ideation

Ø 28.6% had attempted suicide at least once in their lifetime

Reference: Tsaklakidou et al. 1996

Drug dependence is strongly associated with various aspects ofpsychopathology. Antisocial Personality Disorders, seem to be highlyassociated with illicit drug use, probably because both are manifestations ofdeviancy from social norms.

The high prevalence of suicidal ideation and suicide attempts among drugdependent population could be attributed to the depressive symptomatologydiagnosed.

D r u g s a n d d r i v i n g

A study conducted by the Laboratotry of Forensic Medicine and Toxicology ofthe University of Athens aimed at identifying the involvement of alcohol andother psychoactive substances in traffic accidents in Greece during 1995-1997.

Sample Ø 856 drivers and 89 pedestrians, victims of traffic accidents

Data collection Ø toxicological analysis following autopsy

Main findings Ø 41% of drivers and 19% of pedestrians had blood-alcohol-concentrations over the limit

Ø 6% of drivers and pedestrians had consumed somepsychoactive substance before the accident

Reference: Athanaselis et al. 1999

59

4. SOCIAL AND LEGAL CORRELATES AND CONSEQUENCES

4.1 Social Problems

4.1.1 Social exclusion

Information presented in previous chapters concerning the TreatmentDemand Indicator indicates that the percentage of unemployed users amongthose who demanded treatment, remains relatively stable in the last fewyears. In contrast, their educational level has increased.

In a study designed to examine the profile of young marginalised individuals inAthens during 1997/98, 344 drug users were recruited from the street(European Commission 1998).

According to the findings:

• Twenty percent were homeless.

• Social benefits and charity were reported by around 20% as their mainsource of income, while illegal activities by 4.2%; 30.8% were living on theirparents.

• Only 32% had made contact with drug related services and 15% with othersocial services.

• Despite their serious financial, family and, for some, health problems, mostof them reported drug use as their major problem.

A recent study designed to investigate the relationship between drug use,criminal behaviour and social exclusion on the basis of the history of a sampleof imprisoned drug users, was conducted (Kitsos 2000 unpublisheddissertation). Social exclusion was defined through social, economic anddemographic characteristics, such as place of residence and employmentstatus before imprisonment, educational level, marital status, as well as theirparents’ occupation.

According to the main findings:

• The vast majority of these people were severely socially excluded,according to above definition

• Social exclusion preceded drug use and involvement with criminal justicesystem

• According to their self-reports, social exclusion is “responsible” for theirintroduction in marginalised groups who engaged in drug use and criminalacts.

60

4.1.2 Minorities

Until recently, in Greece ethnic minorities were practically non-existent. Todayminority groups consist of financial immigrants, refugees, people of Greekorigin who were repatriated form countries of the former USSR and ROMS.

A small but increasing number of these people request treatment for drugdependence.

4.1.3 Community problems

Interviews with street workers conducted by the Focal Point, draw the pictureof public reactions to users, especially to neighbourhoods where drug use anddealing is common. The reactions of the people who live or work in suchplaces vary greatly; most react negatively, but pity or indifference are alsoexpressed.

The main concerns of the community are petty crime, thefts, committed byusers and fights among users. Protests come mainly from shop owners, whomaintain that they lose their clientele. Fears for public health are alsoexpressed, because many users are in an wretched physical condition (openwounds, bad odour).

In some places shop-owners have hired private security. In other placespeople do not protest out of fear for retaliation by the users. There are isolatedinstances, where inhabitants have created local unions and they protest in anorganised and formal way to the Police and the Ministry of Public Order.

4.2 Drug Offences and Drug Related Crime

4.2.1 Arrests and charges

The Focal Point collects on an annual basis data on arrests and charges bythe Central Anti-Drug Co-ordinating Unit, of the Ministry of Public Order inaggregated form. According to the law enforcement authorities these datahave 100% coverage, since every individual who is arrested or charged isrecorded without exception. Arrested is an individual caught by the police as suspect for a specific offence.An individual is charged when a specific accusation exists, possibly withouthaving been apprehended. Prosecution of an individual implies beingarrested, charged and brought to court.

Figure 21 presents the trends in the arrests and charges in the last 6 years. In1999, 10,902 charges for drug law offences are reported by all lawenforcement authorities.

61

The majority of the individuals charged were men (84%) of Greek nationality(90%).

Figure 21: Arrests and charges by the Hellenic Police and charges bythe law enforcement authorities (1994-1999)

(1) Customs, Ministry of Finance, Coast Guard. (2) No data available for 1998 for arrestees by the Hellenic Police

SOURCE: Hellenic Police and Central Antidrug Coordinating Unit, 2000

The number of arrests reported by the Hellenic Police constitutes steadilyaround 95% of the total number; for 1999 the Police reported 10,105 arrests,number increased by 67% compared to that of 1997 (in 1998 the Police didnot report data on arrests).

Reports from police officials maintain that the police, in accordance with thedestigmatisation philosophy of the new laws prioritise arrest of dealers ortraffickers of large quantities. The user who possesses small quantities mainlyfor personal use does not constitute the target of the police. Another reasonfor this, is that is has been proven that most of these individuals do notattempt to "recruit" new users.

4.2.2 Convictions and imprisonments

The Statistical Service Unit in the Ministry of Justice, collects data from all theGreek judicial authorities and prisons for every case of final court conviction orimprisonment of a drug law offender. The Focal Point receives these data inan aggregated form.

The latest data available for convictions refer to 1996 and for imprisonmentsto 1997.

0

2000

4000

6000

8000

10000

12000

1994 1995 1996 1997 1998 1999

N Charged by the lawenforcement authorities (1)

Arrested by the HellenicPolice (2)

62

In 1996 the number of convicted individuals presented increase compared tothat of 1995 (1,484 in 1996 and 1,263 in 1995). Convictions for drug use haddecreased, while convictions for trafficking had increased.

Figure 22: Individuals imprisoned for drug law offences (1995-1999)

SOURCE: Statistical Service of the Ministry of Justice, 2000

Individuals imprisoned for drug law offences constitute 50% of the totalnumber of imprisonments. The number of imprisoned individuals remainedpractically unchanged in 1997 (2,069) compared to 1996 (2.014) (Figure22).The majority were men (97%).

As seen in Figure 23, most of the imprisoned individuals in 1997 (79.6%),were convicted for trafficking, 12% were convicted for cultivation, while asmall percentage (8.4%) were imprisoned for use only.

Figure 23: Imprisoned individuals for drug law offences accordingto type of offence (1996-1997)

SOURCE: Statistical Service of the Ministry of Justice, 2000

632 662832

931 9991174

13631588

22702123

18722014 2069

0

500

1000

1500

2000

2500

3000

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Í

8,3

76,3

15,3

8,4

79,6

12

0

10

20

30

40

50

60

70

80

90

Use Trafficking Cultivation

%

1996

1997

63

This picture is compatible with the latest law amendments, which are morelenient to users, especially dependent users, and stricter to dealers andtraffickers.

Health professionals who offer legal assistance to users report that out ofthose imprisoned for drug use, the majority are simultaneously convicted forother offences, often non- related to drugs. This leaves a small number ofindividuals who are imprisoned for use only, who are in this situation becausethey did not show up during trial, either out of fear or because they did notreceive a subpoena, not having a permanent residence. The court not havingany information on them (for example, if they are dependent on drugs)convicts them "in absence".

4.2.3 Drug related crime

The previous statement reported by health professionals is verified by thefindings of a study on criminality among drug dependent people conducted intreatment services and in prison (Kokkevi, et al., 1993). According to theusers self-reports 77.6% had been arrested and 57.1% convicted. Arrests andconvictions for other than drug offences outnumbered the drug offences. Forhalf of the drug-abusing subjects, involvement in crime predated the start ofheroin use. Among the main factors associated with criminality were malegender, polydrug use, unemployment, low educational level, and not injectingheroin as main mode of use.

Results from a follow-up study investigated the relation of imprisonment tofurther criminality. This research examined a sample of 82 drug-dependentsubjects assessed for the first time while in prison and a sample of 123 drug-dependent subjects assessed for the first time while in treatment services.Reassessment took place in the first sample eight years after the firstassessment and in the second sample four years after the first assessment.From the sample in prison, 63.6% were found again in prison at the secondassessment, whereas only 7.9% of the second sample were in prison(Kokkevi 1992).

D r u g r e l a t e d c r i m e i n a d o l e s c e n t s a n d y o u n g a d u l t s Data derive from “STROFI” unit show that, out of those requested treatmentthere, the percentage of adolescents and young adults who had beenarrested at least once in their lifetime has increased in 1999 compared to1998 (from 53% to 59.1%). It must be reminded that “STROFI” adolescentshaving law problems are one of the target groups of “STROFI”. Also increasedis the percentage of those who reported multiple arrests (from 6.2% to 11.2%for 6 arrests or more). The age at first arrest is lowered; in 1999 moreindividuals were arrested at 15 years of age or younger compared to 1998(23% in 1998 and 31.6% in 1999). The majority (56.8%) in 1999 reportedhaving an income from illegal sources (no data for 1998) (STROFI 1998;STROFI 1999).

64

P h a r m a c y b u r g l a r i e s

Figure 24 presents the trend in the burglaries of pharmacies reported in thelast 10 years.

The decrease in the number of pharmacies being burgled in Greece since1991 could be attributed to various factors; The low prices and the increasedavailability of drugs, as well as the intensification of law enforcementmeasures. (Central Antidrug Coordinating Unit 2000).

Figure 24: Burglaries in pharmacies in Greece (1991-1999)


4.3 Social and economic costs of drug consumption

NO INFORMATION AVAILABLE

5. DRUG MARKETS

5.1 Availability and supply

Greece because of its geogrpahical position in the Balcan peninsula, as wellas between the producing countries of Africa and Asia and the consumingones in Europe, plays an important role in the illegal drug market. A largeamount of the quantities seized do not have Greece as their destination. Drug production may also occur in Greece. In 2000 the police tracked down,for the first time in Greece, a clandestine laboratory where illegal syntheticsubstances were produced.

151

108114

57

81

4756

49 47

0

20

40

60

80

100

120

140

160

180

1991 1992 1993 1994 1995 1996 1997 1998 1999

N

65

Most of the quantities of illegal drugs imported in the country comes fromAlbania and Turkey. Bulgaria and FYROM also constitute important sourcesof drug import, the former mainly of synthetic drugs. Trafficking from theNetherlands or Moroco is less often. Regarding drug trafficking inside the country, there is an increasedinvolvement of the Albanian Mafia (Central Antidrug Coordinating Unit 2000).In 1998 91% of the quantities of cannabis seized in Greece came fromAlbanian dealers, while in 1995 the respective percentage was 68%.Quantities of heroin seized from Albanians in 1998 constituted 75% of allseizures, while in 1995 they constituted 16%. Turks are trafficking mainly heroin in collaboration with Christian and Muslimsof Western Thrace. Police officials report that Turks drug dealers are easily adaptable to thechanges in european law. This is probably the reason that Turkey isconsidered today the first country in Europe for drug storage and processing. According to the same officials, Albania and Bulgaria are used for the storageof large quantities of illicit drugs coming from Asia and Africa, because thedrug related laws in these countries are very lenient. Greece has the strictestdrug related laws of all its neighbouring countries and has signed all therelevant international and European treaties. 5.2 Drug seizures

Data on seizures are collected by the Central Anti-Drug Co-ordinating Unit, ofthe Ministry of Public Order and sent to the Focal Point in aggregated form.

Decrease is observed in the quantities of heroin and cocaine seized during1999 (Figure 25).


Figure 25: Seizures of heroin, cocaine and herbal cannabis (1991-1999)

1

10

100

1000

10000

100000

1991 1992 1993 1994 1995 1996 1997 1998 1999

N (kg) Cocaine

Heroin

Kannabis

66

Specifically, in 1999, 97 kilos of heroin and 45 kilos of cocaine were seized,quantities much reduced compared to the previous year. The law enforcementauthorities attribute this decrease to the fact that in 1998 one big seizure (189kg of cocaine) from the Coast guard increased the total number, while in 1999there was no seizure equivalent in size.

Seizures of herbal cannabis also present decrease in 1999, from around 17tons in 1998 to around 14 tons (Figure 25). A big seizure of 5 tons of hashishwas made by the Coast Guard on a ship coming from Morocco.

Table 11: Drug seizures in 1999 made by each of the lawenforcement authorities

Police Ministry of Finance Coast Total

Customs FECO * Guard

Cases 7,014 35 5 166 7,220

Cannabis

a. Cannabis resin (kg) 18,493 1,015 0,77 35,565 55,843

b. Cannabis herb (kg) 11,616.77 2,215.99 8.738 13,841.50

c. Cannabis oil (kg) 2 0.002 2.002

d. Plants (pieces) 46,198 46,198

Opiates 130,349 13,163 0.002 143,512

Stimulants

a. Cocaine (kg) 44.864 0.226 0.429 0.089 45.608

b. Amphetamines (kg) 1.38 1.38

(pills) 175,000 175,000

c. Ecstasy 2,699 116 2,815

Other psychotropics

a. L.S.D. (doses) 210 210

b. Tranquillizers (kg) 80,210 80,210

(pills) 41,668 71 272 42,011

c. Barbiturates (pills) 32 32

* Financial and Economics Crimes Office

SOURCE: Central Anti-drug Coordinative Unit, 2000

As seen in Table 11, the larger quantities of drug seized are made by thepolice. Large quantities are also seized by the Customs and the Coast Guard,as according to the annual report of the Central Anti-drug Coordinative Unit,

67

around 65% of trafficking of cocaine and cannabis is made by sea, in contrastto heroin (3% by sea) (Central Anti-drug Coordinative Unit, 2000).

5.2.1 New trends in drug trafficking

According to data derived from the Law enforcement authorities, new trendsin drug trafficking are observed in 1999.

Production of drugs was revealed for the first time in Greece in 2000. In spring2000, police seized a large amount of precursor substances andamphetamines (26.159 pills) produced in a clandestine laboratory of a localpharmaceutical industry situated in central Greece. This resulted in a sharpincrease in amphetamines seizures (30.106 pills) compared to the absence ofseizures of the substance in 1999 and the very small amount (5 pills) ofseizures in 1998.

The Coast Guard reported a new method of transporting cocaine and herointhrough the ships which transfer illegal immigrants.

The Police reports ordinary mail (in small parcels) as a new method of herointrafficking from Turkey to Greece.

Additional information worth mentioning concerns the pharmaceuticalsubstance “rohypnol”: according to the information sent by the GeneralChemical Laboratory and Financial Economic Crimes Office, 175.000 pills ofRohypnol 2mg (chemical name: flunitrazepam) were seized in Greece whilebeing in transit from the Netherlands to Egypt .

5.3 Price and purity

Information on price and purity is given by the Hellenic Police. Samples of thequantities of each drug seized are sent to the National Chemical Laboratoryfor analysis and the police information is based on these analyses.

For 1999 the purity ranged between 60-70% for cannabis, 40-60% for cocaineand 20-30% for heroin.

The retail and trafficking prices of various drugs is presented in Table 12.

68

Table 12: Retail and trafficking drug prices in 1999 (in EURO)

Retail Trafficking

Cannabis resin 2.91- 5.82 /gr 1,450 – 2,330 /kg

Cannabis leaves 1.45 – 2.91 /gr 291.30 – 582.60 /kg

Heroin 52.43 – 58.26 /gr 14,565 – 29,130 /kg

Amphetamines 3.50 - 4.40 /pill 2.33 - 2.91 /pill

Cocaine 58.30 – 87.40 /gr 29,130 – 58,260 /kg

LSD 5.80 – 8.73 /pill 2.91 – 4.36 /pill

Ecstasy 11.65 – 23.30 /pill 5.82 – 8.73 /pill

SOURCE: Hellenic Police, 2000

Cocaine is by far the most expensive drug, followed by heroin. Cannabisprices are very low, when a packet of tobacco cigarettes costs between 1.7and 3.50 EURO in Greece.

6. T RENDS PER DRUG

6.1 Cannabis

Cannabis is the most popular illicit drug according to data from the 1998general and school population surveys. Among the student population, thelifetime prevalence has doubled in 1998 compared to 1993 (4.6% and 12.6%,respectively). In the general population (ages 12-64) cannabis prevalence is12.2% in 1998, that is three times higher than what it was in 1984, when theprevious nationwide survey in the general population was conducted. Men arethree times as many as women (18.8% and 6%, respectively). Young adults(18-35 year olds) present the highest prevalence (around 22%).

Of the students and the young adults aged 18-24 years who report cannabisuse:

• the majority report use with friends of the same age or their girl/boyfriend.

• 22% of students have used cannabis during football matches and 30% atschool.

• young adults prefer using cannabis at home, while high-school studentsprefer open spaces, probably because they live with their parents.

Data from the treatment demand indicator in 1999 show that cannabis is formost users (75%) the first substance they ever used, but only 6.9% reportcannabis as the main substance of abuse. Compared to 1996, in 1999 heroinusers who report cannabis as the secondary substance of abuse haveincreased (from 49.8% to 60%). (Treatment demand data on users requestingtreatment for cannabis use are presented in Chapter 3.1 Treatment demandfor cannabis)

69

Contrary to the treatment demand indicator data, the majority of adolescentand young adult users who request treatment at “STROFI” in 1999 (seeChapter 2.3, Figure 7) report cannabis as their main substance of abuse(48.9%) (STROFI 1999).

6.2 Synthetic drugs

Ecstasy use is reported by 2.1% of high-school students and 0.2% by peopleaged 12-64. Its use is more popular among club/party goers (12.5%), while itsprevalence among dependent individuals requesting treatment is 1.6%.

Out of the students ecstasy users, 35% have used it during football matchesand 27% at school.

Students and young adults (18-24 years) consume ecstasy mostly in raveparties.

As seen in Figure 26, adolescents who frequent clubs and parties are betterinformed on the risks of simultaneous use of ecstasy and other substancesthan high-school students in general.

Figure 26: Simultaneous use of ecstasy and other substances byhigh-school students and club/party goers

SOURCE: Kokkevi et al. 1998

The use of hallucinogens (mainly LSD) has doubled between 1993 and 1998in the school population (1.3% in 1993 and 3% in 1998), while in the general

6,7

13,3

6,7

77,1

83,3

41,2

0

10

20

30

40

50

60

70

80

90

100

Ecstasy with cannabis Ecstasy with medicinaland illicit drugs

Ecstasy with alcohol

%

Ecstasy users amongclub/party goers 17-19

Ecstasy users among schoolpopulation 17-19

70

population, use of hallucinogens is low (0.9%).

New information on synthetic drugs:

Use of new synthetic drugs, such as 4-MTA, or other synthetic drugsproducing stimulating or hallucinogenic effects, such as “poppers” (nitrites),“crystal meth” (methamphetamine), ketamine and GHB seem to be limited.This information is based exclusively on the views of the users approachingtherapeutic programmes and it is not confirmed by data from other sources,such as seizures or researches. On the contrary, the increase in ketamine useis verified by various sources (General Chemical laboratory, qualitativeresearch data).

For additional information on synthetic drugs see Chapter 2.1 Youth culture.

6.3 Heroin/opiates

Heroin prevalence among the general and the school population is very low(0.4% and 1.1%, respectively). Insignificant changes have been observedthrough the years.

Heroin prevalence is also low among club/party goers, and is mainly used bythose aged 25-29 years old who are multi-drug users.

On the contrary, among drug dependent individuals, information fromtreatment demand data indicate that heroin continues to prevail as the mainsubstance of abuse (89.1% among individuals seeking treatment in 1999).

6.4 Cocaine

See Chapter 13. Cocaine and base/crack cocaine.

6.5 Multiple use

Use of more than one substance was reported by 7.3% respondents from thegeneral population and 2.3% form the student population.

Multiple use among users who requested treatment seems to have increasedbetween 1996 and 1999, as seen in Figure 27.

71

Figure 27: Number of substances used by clients requestingtreatment in 1996 and 1999

SOURCE: Greek REITOX Focal Point, 2000.

More than half of the 1999 sample of users (55%) report use of threesubstances compared to 35.8% in 1996. The percentage of users who useone substance only decreases accordingly.

Alcohol and drugs

Data from the general population surveys indicate that in 1998 compared to1984, alcohol consumption among drug users has decreased, both in terms offrequency and heaviness (Figure 28)(Terzidou et al. 2000).

Figure 28: Very frequent alcohol consumption among drug users andnon-users between 1984 and 1998

SOURCE: UMHRI, 2000

25,5

38,735,8

13,1

31,8

55

0

10

20

30

40

50

60


%

1996

1999

15,6

50

10,6

33,8

2,4

10

16

42

10,1

27

4,16,5

0

10

20

30

40

50

60

Non users Users Non users Users Non users Users

%

1984

1998

1

72

Although drug users continue to drink more than non-users, differencesbetween illicit drug users and non-users seem to be decreasing in the last 15years. This is probably related to the fact that through the years the group ofusers becomes larger and includes more socially integrated populationgroups.

7. CONCLUSIONS

7.1 Consistency between indicators

Common conclusion from all epidemiological indicators, direct and indirect, isthe increase in drug use in Greece in the last years. Increase in availability isalso apparent both in self-reports of recreational and dependent users and indata deriving from the law enforcement authorities. The decrease inpharmacies burglaries is another evidence for increased availability of drugs.

Increase resulted in the geographical spread of use; although Athens andThessaloniki remain the first areas in drug use prevalence, urban and ruralareas are closely following, as survey findings indicate. This is also evidencedby the number of drug related deaths, according to which increased rates ofdeaths due to acute intoxications are seen in urban and rural areas. It must benoted, though, that the increase in deaths in the non-metropolitan areas isalso due to the increased sensitisation and alertness of the police in the lastyears.

Quantitative and qualitative data conclude that drugs in the second half of the90s decade, are mainly consumed for recreational purposes, increasingly so,following the picture prevalent in other European countries.

In contrast, drug dependence does not seem to have radically changed in thelast few years. Nevertheless, increased number of drug users seekprofessional help, probably as a result of the enhanced sensitisation andawareness of users. Increased number of women demand treatment, as therepresentation of women in drug use in general is increasing.

Although risk behaviours, particularly needle sharing, are quite prevalentamong dependent users, HIV infection remains low. This is not the case,though, for hepatitis, an infection spread to the majority of intravenous drugusers.

Criminality and drug use seem to be highly associated; this may by partlyattributed to the antisocial personality disorder common among drugdependent users, but mostly to the nature of the behaviour which necessitatesinvolvement in criminal acts to ensure its continuation.

73

7.2 Implications for policy and interventions

The first priority in prevention should be to address young people in thesettings they seem to consume drugs mainly recreational settings. Theimplementation of specialised programmes is seriously considered by thestate.

Other population sub-groups need special attention as well; minorities, arelatively new kind of cultural group in Greece, are apparently greatly involvedboth in drug use and trafficking. The situation and the needs of this populationneed to be studied and preventive or therapeutic programmes need to beplanned and adjusted to their characteristics or needs.

Socially excluded drug users form another “dark area” regarding research andaction taking. Research findings from the prison settings form only smallindications of the extent of the problem among inmates. Apparently, forbiddinguse in prison by law has only resulted in “burying” an existing and seriousproblem.

Drug use should seize to be considered as a homogeneous phenomenon.Different drugs are consumed by different sub-groups and in differentconditions. Cannabis has become so widespread that specific interventionsmay be needed. Use of synthetic drugs or new combinations have not beeninvestigated thoroughly, neither have the new patterns of use.

Another major priority for preventive strategies in Greece is safe use. It is truethat preventive efforts have been intensified in the last years, but the alarmingdata on deaths and hepatitis require urgent measures. Therapy andvaccination for infectious diseases is also imperative and should beintroduced to all types of therapeutic programmes.

7.3 Methodological limitations and data quality

The law enforcement authorities have improved the quality of data they giveto the Focal Point. This is probably the result of their own involvement inEuropean groups. Still, though, their data cannot provide all the informationneeded for a full understanding of the situation in the country.

Therapeutic programmes seem to have realising more and more theimportance of collective effort and common collaboration to data gatheringand feedback provision.

Obvious as it may be that research has been increasing in Greece, it is stillfragmentary. The various studies conducted are not part of a centralisedplanning and consequently are not planned to investigate identified needs oranswer specific questions.

74

The long overdue estimation of social and economic costs of drug use shouldbe included in policy-makers agenda. It would be most useful for all parties tohave an idea on this dimension of the problems as well.

Finally, the quality of information and data is expected to improve throughevaluation. After several years of implementation of efforts in the areas ofresearch, prevention, and therapy, evaluation is a need, which all parties havemore or less realised. Specific evaluation strategies are being implemented.The results are eagerly expected and will be welcomed by all professionals.

75

PPAARRTT IIIIII

DDEEMMAANNDD RREEDDUUCCTTIIOONN IINNTTEERRVVEENNTTIIOONNSS

76

8. STRATEGIES IN DEMAND REDUCTION AT NATIONAL LEVEL

8.1 Major strategies and activities

Following the proliferation of the prevention and the therapeutic programmesduring the last three years, emphasis was given in 2000 not only on thedevelopment of new services but mainly on the promotion of quality assurancein the demand reduction field. Within this framework, combined efforts frompolicy makers and professionals working in the drugs field focused onacknowledging the gaps at the provision of services in terms of both quantityand quality as well as on taking action to respond to the drug users’ needs moreeffectively.

Thus, on the grounds of the necessity to support the existing structures alongwith envisaging new programmes adjusted to the current needs, the majorstrategies of the national demand reduction policy for the year 2000 wereaiming at:

• Ensuring the development and effectiveness of the existing preventionprogrammes

• Continuing the establishment of new prevention centres nationally

• Expanding therapeutic programmes (i.e. drug-free, substitution, low-threshold programmes) in regions where treatment options are lacking

• Establishing methadone maintenance programmes

• Creating specialized services for drug users with special needs, such asadolescents, prisoners, culturally different people, hidden populations

• Providing ex-drug users with further opportunities for their social re-integration and vocational rehabilitation

• Consolidating systematic and effective collaboration of all the responsibleagencies in order to promote professionals’ training and programmes’evaluation.

At primary prevention level, the establishment of nine new prevention centres in2000 resulted to their increase up to fifty-one centres overall (Annex I-Table I),while seven more are foreseen to be inaugurated until the end of the year.Students as well as their teachers and parents prevail as the main target groupsof preventive programmes, but at the same time more emphasis was given tothe community agents’ involvement in preventive activities. Moreover, healthpromotion programmes at secondary schools, which take place under theinitiative of the Ministry of Education, were also increased.

An initiative of high importance was the evaluation study on the difficulties andneeds of the forty prevention centres, which had been established by theOrganization Against Drugs (OKANA) in co-operation with the local authoritiesuntil December 1999. The study was conducted by the OKANA and the GreekREITOX Focal Point from December 1999 to February 2000. Adoptingpromotion of quality at the prevention field as an ultimate goal, the results fromthis study constituted the basis for a concrete policy to be planned in order to

77

overcome the existing difficulties and to cover the prevention agents’ scientificand educational needs more effectively.

Based on research data and clinical experience, new therapeutic and harmreduction services were planned during 2000. The establishment of theseservices is foreseen to cover the demand for treatment agencies at local andregional level as well as to respond to the needs of specific groups of drugusers. Within this framework, a methadone maintenance unit has already beeninaugurated in Athens, many of the existing regional therapeutic programmeshave expanded their services to adolescents drug users and they haveimplemented street-work interventions at the local communities. Apart fromthese initial steps already made to expand the network of therapeutic servicesnationwide, the majority of the new programmes are envisaged to beestablished within the period 2001-2003.

The vocational and social rehabilitation of former drug users was another areaof intervention on which emphasis was laid. Having being initiated in 1998-1999, the development and implementation of vocational training programmeswas systematized in 2000. Moreover, a plethora of creative and cultural eventswas organized, under the scope of ex-drug users’ social integration within thewider community.

Training of professionals was also reinforced through the publication of neweducational materials, the organization of seminars and conferences on a moresystematic basis and the co-ordination of meetings to exchange experience andopinions. The main themes of these training programmes concerned effectivemethods of intervention in different scopes of work (i.e. prevention at theprimary education, drug counselling, street-work programmes) as well as thepromotion of an evaluation culture in the demand reduction field.

8.2 Approaches and new developments

Taking into consideration that drug use and drug-related problems call for multi-level strategies adjusted to the local social context and the different needs ofdrug users, developments at primary, secondary and tertiary prevention levelwere as follows:

Primary Prevention Interventions

OKANA continued the establishment of new prevention centres at the local andregional level, which are established progressively since 1996 (Figure 29).

78

Figure 29: Prevention centres established by the OKANAper year of inauguration

SOURCE: OKANA, 2000

In 1999-2000, special emphasis was given on the implementation of preventionprogrammes to primary education students and to youth outside schools. In thiscontext, new educational materials were published and systematic training ofprofessionals on these particular type of interventions was further developed.

Secondary Prevention Interventions

The main trend in the therapeutic field in 1999-2000 was the expansion of newtreatment programmes at the local level and the provision of new services thatcover the particular needs of specific groups of drug users.

In 1999, a specialised therapeutic programme for addicted mothers that enablethem to enter into treatment while their children will also be taken care of byspecialised staff at a nursery addressed to them, started to fully operate withinthe premises of the KETHEA therapeutic community “ITHAKI”.

“ITHAKI” also developed the Support Centre for Prisoners and DischargedPrisoners in Thessaloniki. The centre runs two supportive structures, bothwithin and outside the prison setting, aiming at harm reduction, enhancingmotivation to treatment, rehabilitation and social reintegration.

Many treatment units addressing adults started in 1999 to offer their services toadolescents drug users, as an attempt to meet the increased needs of thispopulation and in order to cover the lack of treatment programmes foradolescents at the local and the regional level. In this context, the “ITHAKI”(Macedonia), “ARIADNI” (Crete) and “EXODOS” (Central Greece) therapeuticprogrammes of KETHEA provided counselling and therapy to adolescents drugusers and to their families. The creation of specialised therapeutic programmesfor adolescents at these regions as well as at other towns in the country is oneof the main future plans of national drug policy. Innovative interventions have

2

21,6

45,1

13,717,6

0

10

20

30

40

50

60

1996 1997 1998 1999 2000

%

79

already taken place regarding counselling and therapy of juvenile delinquents,in an attempt to prevent increase of deviant behaviour and of otherpsychosocial problems.

Streetwork initiatives have also been expanded at the local level. Professionalsworking at the existing therapeutic programmes as well as drug users who areunder treatment implemented several streetwork interventions with the aim toinform drug users about infectious diseases and other risks from drug abuseand to motivate them for drug treatment. Outreach work is foreseen to beexpanded in Thessaloniki in the near future, with the inauguration of an well-organized law threshold service there by OKANA.

Based on the need to further expand therapeutic programmes at local level,OKANA has planned in 2000 the inauguration of new treatment services in thenear future. These will consist of both drug-free and methadone substitution /maintenance services. In particular, three substitution and four maintenanceunits as well as two drug-free programmes are planned to be established inorder to cover local needs nationwide. The first methadone maintenance unithas already started to operate in Athens, since July 2000.

Tertiary Prevention Interventions

Since 1998, the promotion of after-care and rehabilitation programmes as wellas the provision of vocational opportunities to former drug users have becomean issue of high importance. These developments emanated in order to meetthe social needs of ex-addicts and thus to prevent relapses and to reinforce thetherapeutic outcome of treatment programmes. Within this framework,treatment agencies and the Ministry of Labour and Social Welfare continued inthe next two years to offer innovative social and vocational rehabilitationinterventions for ex-addicts.

In 1999, the KETHEA therapeutic programme “DIAVASSI” developed a WorkClub aiming at assisting former drug users in their pursuing for a job and atsupporting those who work already. The Work Club carries out several activitiesranging from organizing seminars on working issues to coming in touch andsensitizing employers about former drug users in search of a job.

In 2000, vocational training and social rehabilitation centres were alsodeveloped by OKANA for ex-addicts who complete substitution treatment aswell as for long-term substitution clients.

The Ministry of Labour and Social Welfare continued in 2000, in collaborationwith the Employment Organization of Labour Force, to provide subsidizedvacancies to ex-addicts and discharged prisoners in order for them to work atthe private sector. Financial assistance to those belonging in these groups whowant to run their own business has been, also, offered.

80

Socio-cultural developments and developments in public opinion

The lay public appears to highly support prevention and therapeutic initiatives.This is evident from the fact that local communities encourage and in manycases demand the development of new services, which will either prevent orcombat drug use at the local population. Moreover, the creation of manyvolunteer groups at the local and regional level aiming at contributing to drugprevention proves that community agents have become strongly sensitized indrug issues. The Mass Media, especially the local Press, have also beeninvolved in informing the lay public on the several developments in the demandreduction field, and thus play an important role in sensitizing the generalpopulation. Another development in the socio-cultural context regardingdemand reduction is the implementation of an increased number of culturalactivities at the local communities, which in many cases are organized by thelocal authorities.

Meetings and conferences in 1999-2000

Along with these initiatives, demand reduction programmes and researchagencies organized several meetings and conferences on drug-related issues.Most of them are listed below:

1. Meeting on “Evaluation of the Therapy organizations related to drugaddiction: Policy and Implementation”, Athens, 11 November 1999,organized by KETHEA under the auspices of the Ministry of Health andSocial Welfare.

2. Press conference organized by the University Mental Health ResearchInstitute and OKANA in Athens on 22 November 1999, on the occasion ofthe presentation of the EMCDDA 1999 Annual Report for Drugs and DrugAddiction.

3. Meeting on “Health in Prisons – Facing the Drug Problem”, Athens, 27November 1999, within the framework of the programme “Health in Prisons”,organized by the European Regional Office of the World Association ofHealth in co-operation with OKANA

4. Meeting on “Counselling and Psychosocial Support in the Prevention andConfrontation of AIDS”, Athens, 11 December 1999, organized by the GreekCounselling Association in co-operation with the Greek Help Line & theCouncelling Centre of AIDS

5. Meeting on “The role of the Local Authority in the Promotion of Health”,Thessaloniki, 24 May 2000, organized by the Prevention Centre “PYXIDA” inco-operation with OKANA.

6. Open Day Session on “Special Populations in Drug Addiction: The necessityfor a new approach”, Athens, 29 May 2000, organized by KETHEA underthe auspices of the Ministry of Health and Social Welfare.

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7. Press Conference organized by the University Mental Health ResearchInstitute in Athens on 3 July 2000, on the occasion of the presentation of theGreek Annual Report for Drugs and Drug Addiction in Greece.

8. Meeting on “Addictions: Consequences and New Approaches”, Athens, 18September 2000, organized by KETHEA and the Addiction TechnologyTransfer Center – University of California San Diego, under the auspices ofthe Ministry of Health and Social Welfare.

9. Meeting on “Refugees and social exclusion”, Athens, 16 October 2000,organized by Karitas Hellas under the auspices of Caritas Europa.

10. 4th Panhellenic Meeting of Prevention Agencies, Heraklion, Crete, 24-27October 2000, organized by the Prevention Centre of Heraklion (KESAN),under the auspices of the Ministry of Public Health and Social Welfare, theMinistry of Education and Religious Affairs, the Municipality of Heraklion andthe Organization Against Drugs (OKANA).

New research findings

In 1999-2000 research in demand reduction issues was also developed.Research regarding policy on drugs shows that drug users and addictedpersons benefit from a meticulously structured institutional framework and therespective therapeutic infrastructure (Mavris et al 1999). In addition, theimplementation of a comprehensive multidisciplinary policy in the field of drugabuse including primary, secondary and tertiary prevention proves to bebeneficial for the target-population (Malliori et al. 1999). For instance, insecondary prevention the expansion of all types of therapeutic approachesappears to motivate more addicts to apply for treatment. Moreover, theestablishment of the OKANA First Aid and Support Center with its Mobile Unit,the street-work programme and the other harm reduction interventions hasshown to reduce the risk factors at both the individual and the public level.

Regarding research findings on drug use prevention and treatment, it has beensuggested that research data are exploited to a limited extent in terms ofplanning interventions in this field. This seems to be attributed to the lack ofcommunication between researchers and practitioners as well as betweenresearchers and policy makers (Kokkevi 1999). Studies conducted in healthservices for drug addicts show that the promotion of health attitudes raises drugusers’ awareness on mental health and detoxification issues. (Papoutsopoulouet al. 1999). Evaluation studies on training programmes addressing healthprofessionals suggest the following: a. health professionals have difficulties inintegrating new knowledge and in incorporating it into practice, and b. there areno clear boundaries between the role of each professional working in the drugprevention field (Mostriou et al. 1999).

Recent research studies on adolescents’ treatment indicate that the main focusof interventions should be on the involvement of the whole family, the nuclear

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and sometimes the extended one, as well as to the adolescents’ education(Kalarritis 1999). Other studies regarding juvenile delinquents demonstrate thatonly 4% of the adolescents who are in correctional institutions are provided withsome kind of support from social services (Aristoteleion University ofThessaloniki 2000). Findings of this study indicate that the most effective policyagainst criminal behaviour consists of a more comprehensive social policy.

9. INTERVENTION AREAS

9.1 Primary Prevention

9.1.1 Infancy and family

Although interventions in pre-school children are still limited in Greece – due tothe fact that prevention policy is focused on primary and secondary schoolchildren – family programmes are continuously expanding. The furtherpromotion of interventions aiming at parents appears to result not only from theestablishment of new prevention centres, but mainly from the increasedsensitization of parents to participate in such programmes.

One of the main evaluation outcomes of the previous years’ family programmesnationwide was most participants’ willing to further attend them in the future andto sensitize other parents to participate, too. Thus, this positive effect ofprevious interventions contributed for the overall number of parents whoattended drug prevention programmes in 1999 (1.813 persons) to be doubled incomparison to 1998 data (930 persons). Stability of participation and fewerdropouts, also, characterized family interventions in 1999.

Moreover, current data show that some practical difficulties of previous years’interventions, such as the limited involvement of fathers in preventionprogrammes and the lack of attendance by parents with pre-school or primaryschool children, tend to be resolved in a considerable number of preventioncentres. For example, the Prevention Centre of the Municipality of Nikaia(Athens) reported an increase in fathers’ participation in the family seminarsfrom 2% in 1998 to 13% in 1999.

The objectives of all programmes aiming at parents, independently of the age oftheir children, still focus on the personal development and support of their rolerather than on information about drugs. Priority is, thus, given to the expressionof their feelings, to the improvement of their relations with their children andpartners and to the development of communicative skills.

Process evaluation of the one-year “Sensitization Programme for Parents”implemented by the Prevention Centre of the Municipality of Alimos(Athens) showed that training in communication skills was considered by themajority of the participants as the most important aspect of the programme.Also, role-playing and provision of specific examples were evaluated as themost effective techniques. These were also the results of the programmeentitled “Intervention in the family”, which started to be implemented in January

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1999 by the Prevention Centre of the Prefecture of Thessaloniki “ELPIDA”.In particular, 91.3% of the 125 participants regarded the alternative ways ofcommunication to be the best part of the programme, while 98.7% stated thatexperiential training and role-playing kept their interest throughout the seminars.

The Drug Dependence Prevention and Health Promotion Centre "PYXIDA"(Thessaloniki) implements parents' schools since May 1998 aiming at informingparents about the developmental stages of children and the factors thatcontribute to a healthy psychosocial development as well as at supporting themto their parental role. Based on an evaluation questionnaire administered to the336 parents who participated in the programme in 1999, results showed that theobjectives of the parents’ schools were achieved to a high degree (Table 13).Moreover, those who systematically attended the programme created a groupof volunteers, which play an important role in sensitizing other parents in thecommunity.

Table 13: Evaluation results of the “Parents’ School” programme of thePrevention Centre “PYXIDA”

Parents with children in:Parents’ Replies

Infancy%

School age%

Adolescence%

Acquisition of knowledge regardingchild psychology 81 84 88

Feeling more secure regarding theirattitudes towards their children andlearning new ways of solving theirproblems

90 92 71

Working through their feelings andworries 90 92 83

Regarding interventions in kindergarten the Prevention Centre of theMunicipality of Alimos implemented in 1999 a health promotion seminaraddressed to infant school teachers. The seminar aimed at informing andsensitizing teachers in primary prevention issues and at supporting them toimplement health promotion programmes at their nursery schools. Althoughevaluation did not include quantitative indicators, qualitative evaluation datashowed that the seminar provided the participants with the opportunity toconsolidate previous knowledge and experience and to organize their futureinterventions within a specific framework.

9.1.2 School Programmes

Although both drug-specific and drug non-specific prevention programmes arestill not mandatory at school, interventions in the student population are the firstpriority of prevention policy nationwide. Within this framework, in 1999-2000special emphasis was given on the enactment of a holistic prevention approachembracing all different school levels. Thus, albeit interventions at the secondary

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education level predominate over the others, prevention programmes inprimary-school children are continuously expanding, whereas new interventionsaddressing University students are organized.

School prevention programmes at the primary and secondary education levelsinvolve teachers, parents and the community as agents of change. In thiscontext, prevention centres organize experiential seminars for teachers, schoolor groups of parents and information-sensitization seminars for the localcommunity agents (i.e. local authorities, the Church, police officers, lawyers,pharmacists, doctors, etc.). Moreover, most of them organize youthprogrammes outside schools in parallel with the school programmes and theyprovide secondary prevention services to students who have drug problems andto their families through referrals to therapeutic units.

The objectives of the prevention programmes at the primary and secondaryeducation are conceived according to their three main target-groups: students,teachers and parents (Table 14 ). In order for the delineated objectives to beachieved, the most common approaches used are the active and experientialeducation through the systemic and community models as well as thepsychosocial, the cognitive and the health education approaches.

Table 14: Objectives of the school prevention programmesaccording to their target-groups

Target-groups Objectives

Students

• To develop personal and social skills (i.e. problem-solvingability, resistance to peer-pressure, responsibility, alternativeways of communication)

• To enhance self-esteem, decisiveness and autonomy• To promote co-operation and solidarity and to improve

interpersonal relationships within the classroom• To promote healthy life attitudes and creative activities

Teachers

• To develop active communication and positive atmospherewithin the classroom

• To improve their pedagogic relation with their students (i.e.application of active learning methods)

• To establish close co-operation with parents and the localcommunity

• To be involved in the organisation of preventive activities intheir schools

Parents

• To develop communicative and interpersonal skills withintheir families

• To support them in the parental role• To establish close co-operation with teachers• To be involved in the organisation of preventive activities

within the schools

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According to the information presented in Table 14, school preventionprogrammes focus on life and social skills development of the general studentpopulation rather than on high risk groups. However, prevention centresimplement specific interventions in students of high risk on request by theirteachers and when it is considered to be necessary they refer them tospecialized counselling and/or treatment services. Within this framework,sixteen youth counselling centres have been established in proximity to schools,whereas further ones are envisaged in the near future.

Apart from the local prevention centres, the Ministry of Education also plays animportant role in promoting primary prevention in secondary schools, throughthe organisation of health promotion programmes nationwide. In particular,1.360 programmes were implemented during the academic years 1997-1998and 1998-1999, whereas in 1999-2000 the number of the respectiveprogrammes was 740, from which 14.5% regarded drug prevention issues.Moreover, the prevention from drug use was the subject of 21% of 52 pilothealth promotion programmes implemented in 2000.

Since December 1999, the OKANA participates actively in the implementationof the European project entitled “Away from Home – Drug Prevention AmongUniversity Students”. This project, which will last up to June 2001, aims atreducing drug demand as well as the risks from drug use among Universitystudents. The particular objectives are as follows:

• To organise counselling, information and referral services within the pre-existing settings of psychological support provided to University students

• To provide specialised training in drug prevention and treatment issues tothe health professionals working in these settings

• To create and publish information material regarding drug prevention, whichwould be adjusted to the particular needs of University students.

The specific guidelines for the implementation and evaluation of this project areunder development. Nevertheless, evaluation of school prevention interventionsand health promotion programmes at the primary and secondary education hasalready been advanced, which is evidenced by the fact that an increasingnumber of prevention centres conduct internal evaluation of their projects everyyear.

The evaluation results of the pilot health promotion programme entitled“Prevention of drugs, promotion of interpersonal relations and combatingacademic stress” confirmed that its objectives were achieved to a high degree.The programme was implemented in the academic year 1998-1999 by the“PROTASI” prevention agency in co-operation with the Prevention Centre ofthe Prefecture of Ahaia. It addressed 194 students of secondary education as

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well as their teachers and parents. According to the students’ replies in theevaluation questionnaire, 65% of them mentioned that the atmosphere of theclass was ameliorated, due to the fact that co-operation and trust amongclassmates were enhanced. In addition, students reported that many attitudesand behaviours of theirs as well as knowledge about certain aspects changedfrom “moderately” to “very much” as a result of the particular programme (Table15).

Table 15: Students’ replies regarding changes in attitudes and knowledge following the programme “Prevention of drugs, promotion of

interpersonal relations and combating academic stress”

Aspects of behaviour and knowledge %

Controlling academic stress 83.4

Resistance to peer-pressure regarding drug use 76.7

Coping effectively with difficult situations at school 75.1

Coping effectively with difficult situations at home 68.9

Increase of knowledge about drugs 68.9

Increase of self-knowledge 68.4

9.1.3 Youth programmes outside schools

Following the establishment of a close co-operation between prevention centresand actors of the local communities (i.e. schools, parents’ associations, localagencies and media), youth programmes outside schools were furtherdeveloped in 1999-2000. In most cases, these are organized in collaborationwith local cultural associations and athletic clubs, and complement schoolprogrammes at primary and secondary school children. Within this framework,they are based on the principal rationale of the prevention school programmes,which is to promote health attitudes as well as to develop personal and socialskills.

Youth programmes outside schools consist mainly of leisure activities, culturalevents and creative communication groups addressed mainly to adolescents,but to pre-school and primary school children, as well. Special emphasis is alsogiven on approaching boy scouts, girl scouts and group leaders in holidaycamps, as well as high-risk young people, e.g. unemployed and schooldropouts. The main approaches used are the group-centered model, active andexperiential learning and peer education.

The Information-Prevention & Sensitization Center Against PsychoactiveSubstances «KEPEPSO» of the Prefecture of Messinia organized in 2000 amixture of various youth programmes outside school, aiming at promoting co-operation among young people and at enhancing their creativity and theirpersonal skills, in general. The programmes that appear to be of high interestare the following:

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• “Feelings and colours”: Experiential workshop addressed young peopleaged 14-16 years old, which aimed at training them in expressing theirfeelings.

• Co-operation among adolescents aged 16-17 years old in order to produce afilm on adolescence.

• Toys’ construction competition among primary and secondary schoolchildren. Children produced toys during their teaching hours with theirteachers’ and parents’ help.

A preventive intervention entitled «Imagination, knowledge and desire to livebeing our compass» has been implemented since May 1998 by the DrugDependence Prevention & Health Promotion Centre «PYXIDA»(Thessaloniki). The programme addresses young people aged 15-24 years oldand it is based on social learning model and on peer-education. Quantitativeand qualitative evaluation results in 1999 showed that the objectives wereachieved considerably. The total number of participants stated that theprogramme assisted them in developing their social skills and specifically incommunicating with others, in trusting themselves more, in expressing theirfeelings and finally in understanding the role and the influence of their peers.Moreover, they learned to plan, organise and implement preventive and healthpromotion activities aiming at their peers.

In the context of the particular programme, a meeting between secondaryschool children and the local youth intervention group for drug prevention andhealth promotion was organized in 2000. The aim of this meeting was for youngpeople to express their opinions regarding unemployment, education,prevention of drugs and AIDS, environment, free time and entertainment. Theiropinions and suggestions were submitted to local authorities, to social, culturaland athletic agencies as well as to school directors, in order for them to take itinto account in planning and organizing future interventions.

9.1.4 Community programmes

The underlying philosophy of the Greek community prevention programmes isthe following: “Prevention planners increasingly, conduct programmes attunedto the context within which they operate, by taking into consideration that drugrelated problems call for strategies involving all sectors of society and all thechannels running through it” (Malliori et al. 1999, p.90). Hence, prevention isintegrated into a wider programme of community interventions and includes jointactivities for primary and secondary school students, university students,teachers, parents, mental health professionals, doctors, pharmacists, policeofficers, lawyers, journalists, the Church, local associations and the localauthorities.

The Prevention Centres inaugurated by OKANA and co-financed by localauthorities implement community programmes depending on the local needs.Despite their independent action, prevention experts are systematically

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supported by OKANA in terms of training, supervision during planning andimplementation, and evaluation. Training is provided by various institutions andcentres, e.g. the “Educational Centre for the Promotion of Health and thePrevention of Drug Abuse” (UMHRI), the “Anthropos Athenian Institute”(AKMA), the “Human Relations Research Laboratory” (EDAS), the “Centre ofTherapy for Dependent Individuals” (KETHEA), the “Hellenic Centre forIntercultural Psychiatry and Treatment“ and the “Drug Dependency Unit 18ANO” (Psychiatric Hospital of Attica) (see also Chapter 10.4 Training forProfessionals).

The Drug Dependence Prevention & Health Promotion Centre «PYXIDA»(Thessaloniki) implements a community programme entitled «Collective actionin prevention» since May 1998. Up to now, 2.800 persons have participated init. Based on the qualitative evaluation conducted after a two-yearimplementation of the programme, the latter appears to have assistedparticipants in communicating, co-operating and understanding better the rolethat can play in prevention at their local community. As a result, the followingdevelopments were reported:

• A prevention group of volunteers called “THEMELIO” was created in order toinform and sensitize the Parents’ Associations of primary and secondaryschool children in prevention issues. This group co-operates closely with thePrevention Centre in order for parents’ programmes to be implementeddepending on the needs and demands that parents have previouslyexpressed to the group.

• Organizations and agencies that deal with young people of high risk formeda network of communication and of cooperation, with the aim to approachtheir target-group more effectively.

• Information and sensitization interventions by the participant agenciesbecame more systematic and they are implemented under the supervision ofthe Prevention Centre “PYXIDA”.

An innovative intervention at the local community level is the one undertakensince 1998 by the Prevention Centre of the Prefecture of Karditsa. Aiming atintegrating in the wider community the various prevention programmesimplemented each year and at sensitizing the lay public to participate in futureactions, the Prevention Centre organizes a “Local Prevention Week” on anannual basis. Information kiosks, distribution of leaflets and of posters, culturalhappenings, seminars and meetings are some of the initiatives included in thislocal prevention week. Evaluation has shown that this intervention hasconsiderable impact on the local community, since an increasing positiveattitude towards primary prevention as well as towards the programmesimplemented by the Prevention Centre has been reported.

Although the quantitative assessment of the community programmes’ outcomesis still limited, an indicator of their effectiveness may be the widespread creationof groups of volunteers as well as their increased involvement in preventiveactivities at the local communities, nationwide.

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9.1.5 Telephone help lines

While telephone help lines in Greece operated initially only at the national level,there has been an increasing interest since 1998 in expanding their use at theregional and local level, as well. This development emanates from theproliferation of municipal prevention centres nationwide and the need of thepopulation at the local communities to have valid and immediate information ondrug prevention and on specialized agencies of prevention and therapy. At themoment, six help lines operate at regional level by prevention centres or otherlocal agencies, whereas three more cover the needs of drug users and theirrelatives nationwide. All of them are funded by the state and/or by localauthorities.

Except for the “Open Line” of the Drug Dependence Unit “18 ANO”(Psychiatric Hospital of Attica), which was the first national telephone help linein Greece established in 1992, two additional national help lines started to fullyoperate in 2000. The first one is the “SOS Line” of the OKANA, whichcurrently offers referrals and information about treatment options. In order for itsservices to be expanded, specialized training for the professionals working inthe line is now pursued. The second is the “SOS Line” of the “ITHAKITherapeutic Programme” of KETHEA, which was initially developed in 1998as a pilot programme under the URBAN initiative. It provides information,counselling and support to the relatives of drug users. The national help line ofEngland, the ADFAM, trained the personnel and it has also undertaken thesupervision of the particular line. Following this collaboration between the twoservices, the adaptation in Greek and the publication of the ADFAM’seducational material is foreseen in the near future (KETHEA 2000).

At the regional and the local level, two new help lines were established in 2000:a. The “Solidarity Line 1037” developed by The Ministry of Macedonia-Thrace,and b. The “Telephone help line of Aetoloakarnania” developed by the“Odysseus” Prevention Centre Against Drugs of the Municipality ofAitoloakarnania.

The “Solidarity Line 1037” aims at providing social care services andpsychological support to individuals, families and groups being of high risk orwho are socially excluded and they have to deal with hazardous situations. Inparticular, through the coordinated collaboration with the entire network of thesocial and health services in Thessaloniki, the line attempts to offer immediateand adequate help to people with special needs, elders, abused women, formerprisoners, HIV infected people, refugees and immigrants, homeless people,drug addicts and alcoholics. The average number of phone calls per day is ten,while according to the first evaluation data 1.3% of them regard drug or alcoholdependence issues. The staff consists of six psychologists and a sociologist.Although, the respective line currently covers the local needs of Thessaloniki, itsexpansion at the geographical regions of Macedonia and of Thrace isenvisaged in the near future.

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The objectives of the telephone help line of the Prefecture ofAetoloacarnania include: a. information about drugs and their risks, b.reinforcement of the users’ and their families’ demand for treatment, c.information about the therapeutic options and referrals, d. parents’ sensitizationand anxiety reduction, and e. psychological support. The “Open Line” of theDrug Dependence Unit “18 ANO”, which is provided with systematic training bythe FESAT, trained the personnel of the Aetoloacarmania’s line and supervisesthe programme.

Regarding evaluation of the drug-related help lines, results of the “Open Line” ofthe Drug Dependence Unit “18 ANO” are consistent with those reported in 1998(see 1998 Annual Report), whereas evaluation of the newly established lines isstill under development.

9.1.6 Mass media campaigns

The issue of drugs has been a main topic of Mass Media in 1999-2000. VariousTV and radio broadcasts as well as press articles were dedicated to thedifferent dimensions of the drugs phenomenon in Greece, to the availablepreventive and therapeutic options dealing with the problem and to the foreseenpolicy plans of future action. Within this framework, collaboration between MassMedia and therapeutic and prevention centres as well as policy-makers wassignificantly strengthened.

The press gave special emphasis on the coverage of new demand reductioninitiatives, and especially the local press systematically reported demandreduction developments and activities implemented at local level. Moreover, thepublication of reports on drugs (i.e. Greek F.P.’s and EMCDDA’s AnnualReports) gave rise to TV and radio debates on particular issues, such as therole of substitution treatment at the national and the European level. Greatattention continues to be paid on the coverage of various activities organized onthe occasion of the International Day Against Drugs.

A TV programme of high importance was the one entitled “Our own man”, whichstarted to be presented on a weekly basis by a state TV channel at the end of1999. This programme dealt with significant social issues, such as drugs, AIDSand social rehabilitation. A show of an imaginary personal story concerning therespective issue of each episode occasioned discussions at the panel betweenprofessionals, policy makers and persons who faced the problem presented (i.e.drug addicts, their parents, etc.). Moreover, a telephone line was available forother people to participate as well, and to introduce questions and newinformation. The subject of the first programme was the drug addict’s family,while the second one covered the issue of drug distribution and use in Greekprisons. Representatives from therapeutic agencies, from ministries andgovernmental bodies participated in the programme.

Within the co-operation framework between demand reduction agencies andMass Media, the newspaper “Exousia” and the radio station “Planet 104.5” co-funded a concert entitled “Music of the World”, which was organized by the

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KETHEA’s Therapeutic Community “PAREMVASI” in 2000. Through theorganization of this concert, the message that art may contribute to theprevention of drug use was conveyed to the lay public. Moreover, the “9.84”radio station of the Municipality of Athens organized in 2000 a series ofbroadcasts, with the aim to inform drug users and the wider community on theprevention and health promotion interventions implemented by the preventioncentres of Athens. The radio station occupies two former drug users, whocompleted treatment in drug-free therapeutic communities.

In 1999, two documentary films entitled “Drugs in Europe” and “AIDS in theWorld – After the storm”, were offered on their demand to TV channels of eightBalkan countries (i.e. Romania, Albania, Moldavia, Bulgaria, Fyrom, Serbia andCroatia). These films, which were directed by a Greek journalist, were initiallypresented in a state Greek TV channel. The eleven-episode film on drugs thatwas based on a social research, aimed at increasing public awareness on drugsand of social exclusion in Europe by analyzing different parameters (i.e.production, distribution, types of substances, drug user’s profile, effects fromchronic use, prevention, therapy and rehabilitation). The scientific advisor of therespective research was the World Union of Mental Health. Other internationalcompanies and organizations, also, asked to be provided with the particularfilms (i.e. Teleproductions International LTD Virginia USA).

Although information provision to journalists in drug prevention issues has notbeen systematic, it is continuously increasing mainly by local preventioncentres. In this context, and on the occasion of the International Day AgainstDrugs, the voluntary prevention agency “PROTASI” organised in collaborationwith the local press a meeting entitled “Prevention and Mass Media”. The mainobjective of this meeting was to reinforce the role of Mass Media in primaryprevention. In addition, the Prevention Centre “PYXIDA” of the Municipality ofThessaloniki organized in 2000 an educational seminar in co-operation with theTACADE. The seminar considered the influence of Mass Media on the shapingof role models for youth and on the development of critical thinking as a meansof primary prevention.

9.1.7 Internet

The use of the Internet as a means of informing the public on drug issues and ofpromoting drug prevention has not been developed yet in Greece, with the onlyexception of the website www.medinet.gr. This website, created in 1999 by thenon-governmental organization “Social Solidarity”, provides the lay public withfirst aid and drug-related information. Several reasons may be attributed to thelimited use of the Internet for prevention purposes ranging from the preferenceof a personalized approach in prevention work to the lack of adequate technicalinfrastructure at the prevention centres.

Nevertheless, special emphasis has been given in 1999-2000 on ensuring thefinancial and technical means, so as to promote dissemination of preventionknow-how among professionals. Two years ago only a limited number ofprevention centres had access in the Internet, whereas now half of the overall

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number of them has solved this problem. The OKANA envisages for the nearfuture not only to supply all prevention centres with the appropriate electronicequipment, but also to provide them with an electronic chat group, throughwhich prevention agents will communicate among themselves and with expertsfrom the OKANA.

Moreover, apart from its own website (www.hol.gr/umhri) that is available to thepublic since 1997 and which presents updated data on the drug situation inGreece, the Greek Focal Point developed three new electronic databases in2000. These will provide information on the annotated bibliography that coversthe drug-related scientific literature by Greek authors, on the drug-relatedresearch in Greece and finally, on the early warning system. Professionals andscientists of the drug field will be able to have access in them by the beginningof 2001. Two additional databases in the demand reduction field are also beingprepared by the Foal Point. The first one, will be based on the “Inventory of theDrug-specific Prevention and Therapeutic Services” (Boukouvala et al. 2000)and it will consist of the structural and functional data on the prevention andtherapeutic agencies that operate nationwide. The second will offer detailedinformation on the current prevention and treatment programmes according tothe EDDRA questionnaire and it will also provide professionals with theopportunity to exchange experience through electronic chat groups.

The use of the Internet is also limited in the therapeutic field. The KETHEA isthe only therapeutic agency that offers detailed information on its differentprogrammes implemented nationwide, through a website (www.kethea.gr).

9.2 Reduction of drug related harm

9.2.1 Outreach work

More emphasis started to be given on outreach work during 1999-2000. Thus,except for the continuation of the three existing outreach programmes (i.e. theKETHEA “Pegassus” Mobile Unit, the Streetwork programme of the KETHEAMultiple Intervention Centre and the Streetwork Programme of OKANA’s HelpCentre), other therapeutic centres initiated outreach initiatives at local andregional level.

The interventions of “Pegassus” are carried out on invitation by the localauthorities and other local agents with a view to make the local communityaware of the problems associated with the use of drugs and also to motivatedrug users to seek treatment. Thus, the strategies applied are mainly thecommunity/family approach, the public health model and the youth workapproach. In 1999, “Pegassus” visited twelve cities throughout Greece.Moreover, in 1999 “Pegassus” implemented primary prevention programmes atseveral workplaces and programmes outside school for young people aged 15-20 years old. The latter aimed at demystifying drug use and at promoting qualityof free time and entertainment through the organization of alternative activitiesand happenings.

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The streetwork programmes of KETHEA and OKANA take place at drug scenesin the Athens area. Using the “catching client” and the “public health” models,the Streetwork Programme of the KETHEA Multiple Intervention Centrecame in contact in 1999 with 1,524 users being homeless, prostitutes or ethnicminorities. The primary objective of the programme is to establish contact andcommunication with drug users so as for them to be motivated in making eitherminor or major changes in their life.

Based on a harm reduction approach for drug users not receiving treatment, theStreetwork Programme of the OKANA Help Centre, in 1999 approached2,218 drug users. The programme aims at informing drug users about harmreduction from infectious diseases, and at motivating them to adapt healthyattitudes as well as to seek treatment. Thus, counselling and information onsafe drug use, distribution of clean syringes and referrals to the medical andsocial services of the Help Centre are included in its activities.

The Mobile First Aid Unit is another service provided by the OKANA HelpCentre, which offers ambulance services in cases of emergency (i.e.overdoses) and transfers drug users to general hospitals in Athens. In 1999, theUnit provided its services to 1,401 drug users.

Although outcome studies are not systematic due to the nature of the work, ithas been reported that a considerable number of drug users seek treatment asa result from streetwork interventions.

On these grounds, streetwork initiatives were expanded in 1999. TheCounselling Centres of KETHEA have systematized their streetworkinterventions with the aim to inform drug users about infectious diseases andother risks from drug abuse and to motivate them for treatment. For example,the therapeutic programme “EXODOS” organized in co-operation with theMobile Unit “Pegassus” and the local Prevention Centres a ten-day informationand sensitization campaign addressed to drug users in central Greece. Drugusers who are under treatment at the therapeutic community «NOSTOS» alsoundertook a seven-day information campaign. Apart from this campaign, whichtook place at the islands of Argosaronikos, the counselling centre of “NOSTOS”implements streetwork programmes in Piraeus on a regular basis. Outreachwork is foreseen to be expanded in Thessaloniki as well, with the inaugurationof a low threshold service there by OKANA.

9.2.2 Low threshold services

OKANA and KETHEA currently provide low threshold services. Both of themaddress their services to drug addicts who do not wish to enter treatment andwho additionally appear to encounter serious health and social problems.

The Multiple Intervention Centre of KETHEA offers to drug users counsellingservices, psychological support, self-help groups, creative and recreationalactivities, nutrition, clothing and referrals to public hospitals (for moreinformation, see 1998 Annual Report). Moreover, drug users are provided with

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dental services within the premises of the Centre. A development in theprovision of low threshold services was a drop-in centre established in 1999 atthe premises of the Multiple Intervention Centre. This centre entitled “Off Club”,aims at promoting harm reduction from drugs and at motivating drug users fortherapy. It provides hygiene services, nutrition and creative activities. Aninnovation of the Club is a touch screen programme through which drug userscan find information about the services of the KETHEA. In 1999, 1,398 drugusers visited the “Off Club”.

Harm reduction at health, psychological and social level is the primary objectiveof the OKANA Help Centre, as well. In order to achieve this objective, the HelpCentre has developed an well-organized network of services. This includesvarious programmes, the interventions and clients of which in 1999 arepresented below in details:

• A general health clinic of primary care, which also provides systematicinformation on safe drug use. The overall number of clients in 1999 was1,747 drug users.

• A fully equipped microbiological laboratory established in 1999.• A dental clinic, with 728 clients in 1999.• A social service, which provides information on and referrals to therapeutic

programmes and to other social services for housing, employment andfinancial issues. Also, it offers psychological support and it organizesseminars on safe drug use, prevention of infectious diseases and hygieneissues. 302 drug users visited the social service of Help Centre in 1999.

• A legal service, which provides legal advice to drug users as well as legalsupport to members of the Substitution Programmes, in cooperation with theLawyers’ Association. 201 drug users were provided with legal services in1999.

• A telephone help line, which started to fully operate in 2000.• A streetwork programme and a mobile first aid unit (see Chapter 9.1.1.

Outreach Work)• A syringe exchange programme, which is implemented within the Help

Centre. In 1999, 86,819 overall syringes were exchanged.• An early intervention programme for delinquent adolescents (see Chapter

9.6. Interventions in the criminal justice system).

Health and legal services of the Help Centre are available not only for the drugusers who visit the Centre, but also for the clients of the OKANA SubstitutionProgrammes as well as for drug users who are referred by other specializedtherapeutic centres.

Evaluation results in 1999 show the positive overall outcome of the Help Centrework. In particular, the numbers of new and former clients have been increasedcompared to the figures of last year. 1,136 new clients visited the Centre in1999, whereas the number of new clients in 1998 was 635 drug users. Also,while the clients approaching the Centre for a second or third time was 662 in1998, this figure was considerably increased in 1999 (1,842 clients). Anincrease was also reported in exchanged syringes (86,819 syringes in 1999compared to 46,660 in 1998) and in the number of drug users who recovered

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from overdose after the prompt intervention of the Mobile First Aid Unit (1,401 in1999 compared to 1,055 in 1998).

On the grounds of these positive results and in order to cover the lack of lowthreshold services in the city of Thessaloniki, OKANA envisages theestablishment of a Help Centre there in the near future.

9.2.3 Prevention of infectious diseases

See Chapter 14.3: New developments and uptake of prevention, harmreduction and care

9.3 Treatment

9.3.1 Treatments and health care at National level

The existing treatment unit types in Greece are: Drug-free residentialtherapeutic communities (8), non-residential therapeutic centres (9 for adultsand 4 for adolescents), methadone substitution (4) and methadonemaintenance units (1), and low-threshold programmes (2) (Figure 30).

Figure 30: Types of therapeutic programmes in 2000

SOURCE: Therapeutic programmes’ network of the Greek Focal Point, 2000

The main objectives of all types of treatment units include total abstinence fromillegal drugs, improvement of personal and social skills, of health and of familyand social relations, decrease of deviant behaviour and occupationalintegration. In particular, 70% of the treatment programmes refer totalabstinence from illegal drugs to be their main objective, while the developmentof self-esteem and of self-knowledge is the main objective of 20% of thetherapeutic programmes. The well being and the improvement of physical

8

13

5

2

0

2

4

6

8

10

12

14

Residential/drug-free Non-residential/drug-free Methadone substitution

and maintenace

Low-threshold

N

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health and of daily life skills are considered as primary goals by the 10% of thetreatment units.

Along with the treatment, therapeutic programmes also provide other specialservices in order to meet the multiple needs of drug users more effectively. Inthis context, more than half of the therapeutic units provide psychiatric help(60%) and supportive interventions that assist individuals to get a regularoccupation (55%), while half of them offer vocational guidance. Other specialservices which are provided in the context of the main therapeutic procedureare the following: after-care services (45%), housing assistance (30%), basicmedical help (25%), basic/academic education (15%), financial help (10%),vocational training and scholarships (10%).

Moreover, half of the therapeutic units report that they provide services tailoredto special groups of drug addicts (i.e., drug users facing psychiatric problems,adolescents, users under probation, pregnant drug users, etc.). In 1999,adolescent drug users corresponded to the 12.9% of the total number of drugaddicts under treatment.

Regarding most treatment units’ staffing, a total number of 315 professionalsprovided specialised services to drug addicts in 1999. Therapeutic programmes’staff consists mostly of mental health professionals (52.3%). Medical staff (i.e.doctors, nurses) corresponds to the 15.6% of the total number of personnel(Table 16).

Table 16: Staffing of the therapeutic programmes in 1999

RESIDENTIALPROGRAMMES

(�=8)

NONRESIDENTIAL

PROGRAMMESFOR ADULTS

(�=6)

NONRESIDENTIAL

PROGRAMMESFOR

ADOLESCENTS(�=3)

METHADONESUBSTITUTIONPROGRAMMES

(�=4)

TOTAL

� %

Psychiatrists 5 7 - 12 24 7.6

Other doctors - - - 3 3 1.0

Psychologists 9 9 11 15 44 14.0

Social workers 5 6 3 17 31 9.8

Consultants 5 3 - - 8 2.5

Other therapistsor Trainers 28 17 21 - 66 20.9

Nurses 22 2 - 22 46 14.6

Other specializedpersonnel 2 3 1 4 10 3.2

Administrativepersonnel 4 11 3 33 51 16.2

Others1 3 20 4 5 32 10.2

� 83 78 43 111 315 100.0TOTAL % 26.3 24.8 13.6 35.2 100.0

1 Sociologists, art therapists, physical education teachers, education personnel.

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All agencies that run Therapeutic Programmes lay emphasis on the continuouseducation of the staff, the promotion of communication at all levels and theprovision of incentives. Training activities aim to promote scientific knowledgeand know-how, to prevent the burn-out syndrome, to help staff membersdevelop their skills in order to be able to adjust to the ever-changing needs oftheir work and, least but not last, to improve the services provided to addictedpersons and to their families. For example, KETHEA’s training programmesconcern themes, such as drug counselling, counselling to addicted mothers,relapse prevention, health management, family therapy, and street-workinterventions.

Regarding the funding sources of treatment units, most of the therapeuticprogrammes’ expenditures were covered in 1999 by Governmental agencies(57.7%), while funding from European Union and donations covered in most ofthe cases less than 50% of the programmes’ expenses (Table 17).

Table 17: Funding sources of the therapeutic programmes

Percentage of expenditure covering TOTAL

Funding Sources 100% 99%-70% 69%-40% 39%-10% � %

Governmentalagencies 9 4 2 15 57.7

European Union 1 3 4 15.4

Donations 1 6 7 26.9

TOTAL 8 5 4 9 26 100.0

According to the data from the First Treatment Demand Indicator and theKETHEA’s records, the degree of involvement of public health services andGPs in the process of referrals to drug services in 1999 was as follows: 7,3% ofthe total patient population is referred by Hospitals and other medical units,3,6% was referred by GPs and 2,6% was referred by social services. Due to thefact that data from KETHEA are provided to the Focal Point in an aggregatedform, it is necessary to point out that the statistic double counting error comesup to 5%.

The main characteristics of the drug-free residential and non-residentialtreatment units as well as their therapeutic goals are presented below.

D r u g - f r e e R e s i d e n t i a l T r e a t m e n t

Eight out of the twenty-eight treatment units in Greece are residential. Situatedin different parts of the country provide a large range of services to adults drugusers. The treatment lasts approximately from 12 to 15 months and is providedon a voluntary basis. Applying individual and group therapy through a systemic,cognitive or psychodynamic approach succeeds the objectives of these

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programmes, which are abstinence from drug use and emotional maturation.Emphasis is also laid on the continuous educational and vocational training,which contribute to individuals’ rehabilitation. The main characteristics of thetherapeutic programmes belonging in this category are presented below.

“ITHAKI”, the first therapeutic community in Greece established in 1983, issituated at the outskirts of Thessaloniki. Similar to all the other KETHEAtherapeutic communities, “ITHAKI” follows the Therapeutic Community Self-Help Model Approach. It runs a rich educational programme for its members,with classes in literature, judo, pottery, theatre, drawing, music, etc. In 1999, thenumber of clients at the therapeutic community was 156 persons and newadmissions reached the number of 56 individuals.

The counselling units of the Therapeutic Community “EXODOS” are situated inLarissa and Volos, two major cities of Central Greece and they have beencovering the needs of the broader geographical area of this part of the countryfor the last 10 years. Since 1999, “EXODOS” has been providing services to theparents of adolescent users, although the programme is addressed to adults.“EXODOS” is currently planning the establishment of a comprehensivetreatment programme for adolescents that will cover the increasing needs ofthis part of Greece.

The Therapeutic Programme “PAREMVASSI” is located in Attica and has beenoffering services to drug addicts for the last 10 years. Along with the therapeuticservices, the programme is also active in protecting the environment and inrunning other social or ecological intervention projects. For example, in 1999,PAREMVASSI’s interventions included a reforestation project in Attica.

Located in Piraeus, “NOSTOS” not only offers treatment services to adult drugusers and to their families, but also it contributes to the preservation of theGreek nautical tradition by forming a group that aims to maintain the traditionalcraftsmanship of shipbuilding. In 1999, NOSTOS’ groups of silversmithing andcreative writing exhibited and presented their work in Athens and Piraeus.

The network of inpatient services of “18 ANO” consists of a ResidentialTreatment Programme and a programme tailored to the special needs ofwomen (Residential Women’s Treatment Programme). Therapy isapproached in a pluralistic way combining psychodynamic, cognitive andsystemic methods. The residential therapeutic programmes of “18 ANO” providebasic medical care, psychiatric care, individual counselling, group and individualtherapy, self-help groups, family therapy, after-care services and vocationalassistance.

The Therapeutic Community of Karteres belongs to the Drug DependenceTreatment Unit of the Psychiatric Hospital of Thessaloniki and provides groupand individual therapy based on the Milieu Therapy approach.

A residential drug-free programme directed by the First Evangelical Church ofAthens, named “Philimon”, offers help to drug addicts basically in accordance

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with supportive group therapy and Christian principles. In 1999, provided itsservices to 28 drug users.

D r u g - f r e e N o n - r e s i d e n t i a l T r e a t m e n t

There are thirteen non-residential treatment programmes: four non-residentialtherapeutic communities (two for adults and two for adolescents), one day-clinicand eight outpatient centres. Motivation and preparation for treatment,counselling, detoxification, family therapy and rehabilitation are the main typesof treatment services offered by almost all these non-residential units. The maincharacteristics of the non-residential programmes are presented below.

The outpatient treatment units of KETHEA are abstinence-orientedprogrammes, applying a psychosocial approach based on the therapeutic self-help community model in conjunction with the systemic model. Group andindividual therapy services are provided to drug users and members of theirsocial system (parents, brothers/sisters, other relatives, etc.).

“STROFI” is the only therapeutic programme of KETHEA that is addressed toadolescent drug users and their families. The offered services are the following:The Therapeutic Programme for Adolescent Drug Users and theirFamilies, the Secondary Prevention Centre for high-risk young people andthe Counselling Centre in the Public Prosecutors Office in Athens (seealso Chapter 9.5. Interventions in the Criminal Justice System). Allprogrammes offer family therapy aiming at the reconstruction of the familysystem. Also, a halfway house is at the disposal of adolescents from areasoutside Athens.

STROFI’s Secondary Prevention Centre is addressed to adolescents (aged 13-21) who use drugs on an experimental basis, who have educational and/orprofessional activities, and a family background capable of providing support forabstinence from drugs. The Centre consists of four main units: The SecondaryPrevention Counselling Unit, the Secondary Prevention Community, the After-care Unit (Follow-up) and the Unit of Family Therapy and Counselling. Theprogramme aims at preventing further adolescents’ involvement in drugs. Itprovides adolescents and their families with individual, group and family therapyservices, as well as recreational, cultural, athletic and artistic activities. Staffincludes ex-dependent individuals. In 1999, the Secondary Prevention Centreprovided services to 112 adolescents and 287 adolescents’ parents/otherrelatives.

STROFI has established a transitional school for its members who usuallydrop out of school at an early age. The curriculum includes, among others,vocational training and computer literacy. Specialized teachers of alleducational levels and specialized trainers run the classes and specialemphasis is given on handling learning difficulties. Special scholarships aregiven for instructional purposes. Great emphasis is placed on the continuationand completion by users of primary and secondary schooling, supported bypeer-education methods and computers. In 1999, 28 pupils participated and

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succeeded in final exams. In total, during 1999, STROFI’s transitional schoolprovided its services to 62 adolescents.

“DIAVASSI”, a non-residential programme addressed to adult drug users,meets the needs of drug dependent individuals who are able to lead a relativelystable life and who are in fairly good terms with their families that support theirabstinence efforts. Treatment is combined with a multitude of socioculturalactivities such as those held by the “DIAVASSI Cultural Centre” (exhibitions,films, concerts and theatrical plays) in co-operation with the local community. In1999, “DIAVASSI” set up a Work Club in order to meet the needs of former drugusers who are in search of a job. The Work Club of DIAVASSI carries out avariety of activities, such as counselling in order to help its members withproblems related to work and seminars on working issues. The EveningProgramme for working addicts of DIAVASSI is addresed to drug addicts whoare socially integrated, who have a permanent or a part-time job, who followtraining programmes and have family support. The programme aims to helpmembers remain abstinent, improve their ability to work and help them developtheir social skills.

“ARIADNI” therapeutic programme covers the area of Crete. It is an open careprogramme founded in 1999 and consists of a Counselling Centre, aTherapeutic Community (under construction), a Rehabilitation Centre and aFamily Therapy Programme. “ARIADNI” is mainly addressed to adult users, butalso it provides counselling support to adolescent users and to their parents. In1999, the therapeutic communities of KETHEA covered their capacity by 86,6%(KETHEA 2000) and they provided their services to 802 persons.

The Department for Adolescents and Young Adults of the Drug DependenceUnit “18 ANO” has a psychological treatment orientation characterized by thehighly individualized approach of exploring intrapsychic conflicts. Emphasis ison identity problems of adolescents and young adults. Supportive,psychodynamically oriented psychotherapy is the treatment method used by theprogramme. Staff does not include ex-dependent individuals.

The Programme of Family Therapy and Counselling (“18 ANO”) is anoutpatient treatment service addressed to drug users who have a permanentoccupation or attend educational/training programmes and have a rather stablerelationship with their family members who support their efforts. Counsellingand therapeutic services are also provided to family members and otherrelatives based on a systemic approach.

The programme for Dually Diagnosed Persons (“18 ANO”) is addressed todrug users facing psychiatric problems. The programme offers several servicessuch as psychiatric care, individual counselling, group therapy, family therapy,legal support and vocational training.

The Therapeutic Programme “ATHENA” (Psychiatric Department of theAthens University Medical School / OKANA) is an outpatient unit which providesindividual and family therapy interventions in the context of a systemic approachas well as medical, psychological and social rehabilitation services.

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The “IASON” Day Centre of Athens Mental Health Centre provides individualpsychotherapy, group therapy, early intervention and parent group services.The main treatment approach is an individualised eclectic model composed ofpsychoanalytic, person-centered and systemic theory elements.

The OKANA Non-residential Therapeutic Programme “GEFYRA” in Patras(West Greece) consists of a multiphase network of services coveringpsychosocial needs of dependent individuals and of their families. Specialemphasis is given on active family involvement in the therapeutic process.

The Alternative Therapeutic Programme “ARGO” of the Psychiatric Hospitalof Thessaloniki is an outpatient treatment service addressed to drug users whohave a permanent job or follow educational programmes and have familysupport. Counselling services are also provided to family members.

As it may be obvious from the above data, great emphasis has been placed onthe development of long-term stationary, inpatient, high-threshold facilitieswhere admissions are often based upon a waiting list and treatment isabstinence-oriented. The majority of treatment programmes are addressed toadults and the predominant therapeutic approach, which is applied to alltherapeutic communities, is the Therapeutic Community Self-Help Model.

9.3.2 Substitution and maintenance programmes

Following the successful pilot phase of the first two substitution unitsestablished in Athens (capacity 200) and Thessaloniki (capacity 100) in 1996,OKANA inaugurated two more units in these cities (capacity 200 and 150accordingly) in 1998. Along with these four methadone substitutionprogrammes, other therapeutic organizations also prescribe narcoticantagonists whenever it is needed (see 1999 Annual Report submitted to theEMCDDA). The Ministry of Health monitors all these therapeutic programmeson a regular basis.

Admission criteria for all Substitution Programmes in Greece are the following:being an IV heroin addict of more than 22 years of age, having at least a two-year drug use and having unsuccessfully tried other treatment. Priority is givento addicts with HIV, cancer or other somatic illnesses, to pregnant women afterthe third month of their pregnancy, to addicts with psychiatric problems, topeople using drugs for a long time, to polydrug users and to first degreerelatives of clients.

The clients of the four OKANA Substitution Programmes receive methadone asan integral part of their treatment plan, as well as Naltrexone whenever it isneeded. Moreover, the two Substitution Programmes in Athens prescribeantidepressants (i.e. Amitriptyline, Desipramine), benzodiazepines (i.e.Chlordiazepoxide, Diazepam, Alprazolam, Flurazepam), antipsychotics andantimanics (i.e. Tegretol).

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The main objectives of the substitution treatment programmes are gradualdetoxification and harm reduction. Addicts, also, receive psychological supportthrough individual and group psychotherapy, medical support, and assistancefor social integration and relapse prevention. Moreover, psychiatric help, familytherapy, and social skills groups are also provided. The completion criteria oftreatment are total abstinence from all drugs (i.e. negative urine tests for at leastI year) including methadone, improvement of physical and mental health, and ofsocial skills, and successful social integration. Up to now, the duration of thetherapeutic programme was approximately three years.

Nevertheless, after the four-year implementation of methadone substitutionprogrammes, OKANA decided in 2000 on several modifications anddevelopments regarding substitution treatment in Greece, based on specificresearch and evaluation data. According to these data, although the objective ofharm reduction was achieved by 60%-79% of the patients, only 8.5% to 12% ofthem had achieved total abstinence from all drugs including methadone, whilehalf of them had become abstinent within the first year of their treatment.Moreover, despite the fact that demands for substitution treatment werecontinuously increasing, the possibility for new clients to be admitted waslimited because of the accumulated number of addicts staying in the Units forlonger than two or three years. As a result, more than 4,000 addicts arecurrently in a waiting list for substitution treatment.

In order to overcome these problems and to subsequently increaseeffectiveness of substitution treatment, OKANA has already taken the followingsteps:

• The duration of the substitution therapeutic programme aiming atdetoxification was decreased from three years to eighteen months.

• The frequency and the quality of the provided psychosocial services wereincreased, while special emphasis was given on social rehabilitation andrelapse prevention programmes.

• Methadone substitution programmes were separated from maintenanceones. A maintenance unit was already established in Athens (capacity 100)in 2000, while three more with the same capacity each are foreseen to beinaugurated in the near future (one in Athens, one in Piraeus and one inThessaloniki).

Moreover, OKANA envisages to have inaugurated until 2003 three newsubstitution programmes (capacity 60-80) at the regional level and specificallyin Larisa, Patras and Crete.

Attention will be also paid in the systematic and continuous training of thesubstitution-maintenance programmes’ personnel. According to 1999 data, theprofessionals working at the Substitution Programmes are psychiatrists (12),psychologists (15), medical doctors (3), nurses (22), social workers (17) andadministration personnel (33) (Table 16).

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Evaluation of the programmes takes place on a systematic basis. The first dataare collected through a semi-structured interview by a psychiatrist (PompidouGroup’s “Treatment Demand Indicator”). In the course of treatment urine andblood are tested for drugs and infectious diseases. Patients are additionallyaddressed by EuropASI (European Addiction Severity Index) and OTI (OpiateTreatment Indicator), and personal data files are stored in a data bank for thepurpose of statistical analysis. Clinical and laboratory follow-ups take place aftera 6-month period.

Specific outcome data in 1999 regarding the existing substitution units remainthe same with the ones presented in the last year’s Annual Report (see 1999Annual Report submitted to the EMCDDA).

9.4 After-care and re-integration

In 1999-2000, policy-makers and treatment agencies continued to lay emphasison the development of after-care services. Thus, along with the existing ones,new programmes were initiated at this period aimed at drug users whocomplete treatment, discharged prisoners and long-term substitution clients.

In this context, in 1999 the KETHEA therapeutic programme “DIAVASSI”developed a Work Club aiming at assisting former drug users in their pursuingfor a job and at supporting those who work already. In order to achieve theseobjectives the Work Club carries out several activities, which include thefollowing:

• Collecting and organizing printed and electronic information on occupationalissues (i.e., subsidized employment programmes for former drug users).

• Individual and group counselling, so as to help former drug users to copewith stress and with difficulties at their work or in finding a job.

• Organization of seminars on various working issues (i.e., CV composition,developments in the labour market and relationships at work).

• Collaboration and exchange of information and expertise with otheragencies that deal with unemployed persons’ support.

• Information and sensitization of employers about former drug users insearch of a job (KETHEA 2000).

Except of this programme, the Cultural Centre of “DIAVASSI” enriched itscreative and educational activities. In 1999, several individual and group artexhibitions, music nights and seminars were organized, while the first issue of ajournal entitled “Notebooks of DIAVASSI” was published. The journal wasproduced by the vocational training group on graphics, as an attempt to informthe lay public about the therapeutic programme. In 1998-1999, this group hadthe opportunity to attend a subsidized educational programme of 600 hours onelectronic printing.

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Qualitative and quantitative evaluation results from all KETHEA socialrehabilitation centres remain positive. In 1999, 293 former drug usersparticipated in these social rehabilitation centres. The average number ofpersons in treatment was 147, whereas the capacity of the centres is 130places. Being 113% full, the social rehabilitation centres exceeded theircapacity for the fourth consecutive year. Moreover, evaluation results showedthat 100% of participants stay abstinent from all illicit drugs and do not exhibitdeviant behaviour, 95% have a full-time occupation or continue their education,and all of them ameliorate their family and social relations. The 4/5 of all clientsattending the Social Rehabilitation Centres successfully complete treatment.Hostels are provided to former drug users by all KETHEA Social RehabilitationCentres, until they find a job and they are settled down.

OKANA was also active in 1999-2000 in promoting social rehabilitation andafter-care services for former drug users as well as for long-term substitutionclients. A Vocational Training Centre, which started to operate in April 2000,will cover the need for social and vocational re-integration of ninety overallformer drug users. The European Community funds this programme, which isalso co-funded by the Ministry of Labour. Each participant in the vocationaltraining seminars will be subsidized with 5 Euro per hour. Moreover, inSeptember 2000 OKANA developed a social rehabilitation unit (capacity 50)for former drug users who complete methadone substitution treatment in Athensas well as for those who attend the newly established methadone maintenanceprogramme. The programme lasts for a year and provides psychologicaltherapy, vocational guidance and social rehabilitation services. Two more socialrehabilitation programmes (one in Athens and one in Thessaloniki) are foreseento be established in the near future.

The Ministry of Labour continued its initiatives in 2000 to assist the re-integration of socially excluded groups into the job market. In collaboration withthe “Employment Organization of Labour Force” (OAED), it developed newprogrammes addressed to former drug users who have completed therapy andto discharged prisoners. In particular, this initiative includes the followinginterventions:

• The provision of 490 subsidized vacancies at the private sector (300 for ex-addicts and 190 for discharged prisoners). The subsidy will be 20-23 EUROper working-hour for three years.

• The provision of 250 subsidized vacancies of self-employment (120 for ex-addicts and 130 for discharged prisoners). The subsidy will be 15,440EURO.

The “Supporting Centre for prisoners or discharged prisoners”, which isrun by the KETHEA therapeutic programme “ITHAKI” in Thessaloniki, providesfurther rehabilitation and social reintegration services for discharged prisoners,through psychological support, family therapy, and vocational guidance andtraining.

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9.5 Interventions in the Criminal Justice System

Police Prevention Activities

Except of the Educational Centre for the Promotion of Health and thePrevention of Drug Abuse that continued to organize training programmes forpolice officers on a regular basis, most of the prevention centres nationwidehave also expanded their interventions in the local police. The preventionprogrammes addressed to police officers include sensitization seminars onprevention issues as well as information about the existing therapeutic options.

The Prevention Centre for Combating Substances «ELPIDA» of theMunicipality of Thessaloniki implemented in 1999 a respective seminar entitled"Suppression and Prevention: Two sides of the same coin". Evaluation resultsafter the programme’s implementation showed that 87% of the twentyparticipants comprehended the common aspects and the differences betweenprevention and suppression, while 90% of them considered that preventionprogrammes are essential and expressed their will to contribute to prevention.Moreover, all participants stated that the programme assisted them inunderstanding the psychosocial factors that lead to drug use as well as issuesregarding adolescence.

Arrests and referral to drug services

In 1999, 98 adolescents and 150 parents and siblings approached theCounselling Centre for adolescents at the Probation Services Office inAthens. Aside from counselling and treatment services, which have beenprovided since 1998, the centre has also taken up in 1999 a vocational trainingprogramme aiming at preventing adolescents’ social exclusion, at educationalrehabilitation and at abstinence from drugs. This vocational programme, whichis addressed to twenty adolescents, includes: a. training in PCs and in graphic-artistic programmes, b. classes in modern Greek literature, history and culture,c. seminars concerning the adolescents’ rights and obligations, and d. theatricalgames, painting and sports.

The Outreach Pilot Programme for Prevention and Early Intervention inJuvenile Delinquents, which was initiated by OKANA in September 1998,address adolescents aged 13-17 years old, who use drugs on an occasionalbasis and have previous arrests for drug possession and/or use. Adolescentsand their families are referred to the programme by the Juvenile CommissaryService, which constitutes the exclusive source of its referrals. In 1999, theprogramme provided its counselling and psychotherapy services to 38 families.The main objectives are to develop adolescents’ personal and social skills, toassist them in their social integration, to support parents in their parental roleand to promote social networks of solidarity.

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Imprisoned population

Interventions aimed at drug users within prisons are currently limited to thesystematic organization of self-help groups, which are run on a voluntary basisby the KETHEA, the Drug Dependence Unit “18 ANO” and the NarcoticsAnonymous. These programmes aim at harm reduction of infectious diseases,information on the therapeutic programmes, motivation to therapy, andpreparation for enrolment into treatment.

According to the Law 2331/1995, article 21, the successful attendance andcompletion of the support programmes offered to drug dependent prisoners,give them the opportunity to interrupt their custody in order to enroll into atherapeutic community. The time spent in treatment is considered as equivalentto the time the person would spent for the serving of custody. Also, thesuccessful completion of the therapeutic programme leads to a temporarysuspension of the sentence for three to six years.

Four hundrend fifty nine addicted prisoners participated in the KETHEA supportprogrammes in 1999. Moreover, in 1999 the Multiple Intervention Centre incollaboration with the organization “Médecins sans Frontières” carried outseminars concerning health issues, which were addressed to the supportprogrammes’ participants. Further seminars on AIDS and Hepatitis wereorganized for the Women Prisons’ personnel. The Ministry of Justice organizeda congress entitled “Correctional System and Combating of Drug Use” incooperation with KETHEA. The congress was addressed to all professionalsworking in correctional institutions. The two main issues of the congressreferred to the ways of dealing with drug dependent prisoners and the requiredsupport services for discharged prisoners.

Evaluation of support programmes to drug dependent prisoners is currentlyconducted on the basis of the following indicators: number of participants in theself-help groups, consistency of participation, and referrals to therapeuticprogrammes. Results regarding the intervention organized by the TherapeuticProgramme “EXODUS” in the Kassaveteia’s Prison showed that prisoners aswell as the prison’s management highly valued the importance of theprogramme. This resulted to an increase in the number of participants from 6-8drug users to 20 persons after the first sessions.

At the end of 1999, KETHEA also established a Support Centre for Prisonersand Discharged Prisoners run by the therapeutic programme “ITHAKI” inThessaloniki. The Centre has two supporting structures, both inside andoutside the prison setting, aiming at harm reduction, enhanced motivation totreatment, vocational guidance, and rehabilitation and social integration.

The Drug Dependency Unit “18 ANO” has developed since 1995 self-helpgroups for drug dependent prisoners belonging to ethnic minorities.

No syringe exchange programmes, drug testing interventions or treatmentservices (drug-free and substitution ones) are provided within Greek prisons at

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the moment. However, the Detoxification Unit for Drug-DependentPrisoners, which will start to operate in the near future under the auspices ofthe Ministry of Justice, will attempt to cover the lack of treatment options withinthe prison system. In this context, a coordinating committee was formed in2000, aiming at deciding on the principles of the Unit’s operation, on theselection-criteria of the prisoners who will attend the programme, and on thepersonnel’s training.

The main objectives of the Unit are physical detoxification, psychologicalrecovery and social rehabilitation. The Unit will recruit approximately 300 out ofthe 3,000 drug addicted prisoners. Drug dependent prisoners who are eligiblefor being admitted in this treatment programme should have served 1/5 of theirsentence and they should be accused for misdemeanors and not of felonies.Treatment will take place on a voluntary basis. Three types of detoxificationprogrammes will be available in the Unit:

• a drug-free programme addressed to drug dependent prisoners of more than21 years old

• a substitution methadone programme

• a drug-free programme addressed to juvenile and young adults delinquentsof 14-21 years old.

The therapeutic programme will consist of several phases that will include: a.preparation and motivation (2-3 months), b. physical detoxification, c.psychological treatment (1 year), and d. social rehabilitation (1 year). Themembers of the programme should participate in all phases.

According to the findings of the Leonardo Da Vinci research project on theneeds of juvenile delinquents for vocational training (Aristeteleion University ofThessaloniki 2000), only 4% of the young people who are in correctionalinstitutions have been offered some kind of support from social services. In thiscontext, the research team stresses the need for psychological support servicesaddressed to adolescents of this group and to their families to be developed.Moreover, they suggest that a nine-year mandatory education based on thedifferent age groups and group-specificities (e.g. adolescents being foreignspeakers) should be established, so as juvenile’s social and vocationalrehabilitation to be facilitated. Finally, it is required that drug-dependent juveniledelinquents should be referred to specialized programmes.

9.6 Specific targets and settings

9.6.1 Gender specific issues

Two therapeutic agencies have established specialized programmes for womendrug addicts: the Drug Dependence Unit “18 ANO” (Psychiatric Hospital ofAttica) and the KETHEA. Except of these treatment services, the streetworkprogrammes in Athens of OKANA and of KETHEA provide special services fordrug addicted prostitutes who do not approach therapeutic programmes,

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through counselling, motivation for therapy, referrals to public hospitals,condoms and information leaflets for harm reduction.

The Treatment Programme for Dependent Women (“18 ANO”), which wasestablished in 1997, it was developed in an attempt to meet the particular needsof this target-group (i.e. sexual abuse, family neglecting, pregnancy,motherhood, etc.). The therapeutic models, objectives and services provided bythe programme are the same with the ones of the mixed TherapeuticProgramme of the Drug Dependence Unit. Creative activities, such as paintingand literature, are also provided.

The total number of participants in the programme in 1999 was 30 persons.Evaluation results showed that women integrate more easily in society aftercompleting treatment compared to men (74% of women vs. 54% of men), whilethey have a smaller number of relapses (1.7% vs. 7%, accordingly). Womenpraise the advantages of being in a specialized programme, since they feelfreer to express their feelings.

Moreover, in 1999 the KETHEA Therapeutic Community “ITHAKI” inThessaloniki, under the European initiative URBAN, developed a specializedprogramme for drug-dependent pregnant women and mothers who want toenroll in treatment. A nursery for their children is provided through thisprogramme, which is the only one for children of drug users in Greece. Theprogramme is co-funded by the Ministry of Macedonia and Thrace.

9.6.2 Children of drug users

The nursery for children of drug dependent mothers established in 1998 by theKETHEA Therapeutic Programme “ITHAKI” is the only programme for childrenof drug users in Greece. This nursery, which was developed in order to supportaddicted mothers in the process of therapy and social rehabilitation withouthaving to be separated from their children, provide the latter with creativeoccupational and care services by specialized personnel. The programme is co-funded by the European Community and the Ministry of Macedonia and Thrace.

The Child’s Health Department of the Aristotelian University of Thessalonikiconducted an innovative study regarding children of drug users from 1997 to1999 (Georgakas 2000). The main aim of the project was to explore thepossible consequences of parents’ substance abuse on their children. Thesample consisted of 55 children aged from 6,5 months to 11 years old and theirparents. All fathers and 50% of the mothers who participated in the study wereaddicted to drugs. The main methods of data collection regarding childrenincluded the following: a. interviews with parents, b. medical and schoolrecords, c. clinical diagnoses, and d. psychometric tools (i.e Eynzech’sPersonality Questionnaire for Children, Parents Diagnosis Questionnaire).

The research findings showed that the exposure of children to specificconditions results to several physical or behavioural problems. For example,18.1% of the children participated in the study suffered from withdrawal

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syndrome for 48-72 hours after their birth, due to the drugs taken by theirmother during pregnancy. 3.6% of them had been infected with Hepatitis C,transmitted by their mothers. Also, most of the children had emotional andbehavioural problems because of dysfunctional family relationships. Accordingto the results of the Parents Diagnosis Questionnaire, children aged from 13months to 10 years old with drug dependent parents appeared to demonstratehigh rates of: sensitivity (58.8%), disobedience (47%), need for support andprotection (33.3%), jealousy (31.3%), dependence (31.3%), aggression(27.4%), anxiety (23.5%), difficulty to concentrate (19.6%) and short attentionspan (19.6%).

The above findings suggest that drug use by parents has several negativeconsequences to their young children mainly on an emotional and behaviourallevel. Thus, in order to prevent these psychological problems and to take careof them, adequate prevention and counselling programmes need to bedeveloped.

9.6.3 Parents of drug users

Family programmes are well developed in Greece, since drug use is consideredto concern the whole family system. Within this framework, the duration offamily therapeutic programmes is about the same with the duration of drugusers’ treatment. Qualitative evaluation results from all family programmessuggest that parental involvement in treatment motivates drug users to seektherapy, enhances their therapeutic outcome, improves relationships andfunctionality within the family, and promotes relapse prevention.

In 1999, the KETHEA’s six family programmes provided its services to morethan 5,000 parents and relatives of drug users. Out of them, 3,674 personsparticipated in the short-term seminars organized by the family programmes,while 2,617 persons participated in long-term family therapy groups.

A special service for parents is provided since 1985 by the Association forEncountering Drug Dependency (SAT). The programme uses several models,such as the psychodynamic and the systemic approach, the communicativemodel as well as role-playing and drama-therapy. In 1998, eighty personsreceived its services.

9.6.4 Drug use at the workplace

Although no concise policy plan for prevention programmes at the workplacehas been developed yet, prevention centres at the local and regional level aswell as other organisations (i.e. OKANA, KETHEA and Hellenic Institute ofHygiene and Safety at Workplace) implement such programmes on a regularbasis. Their main target-groups are the following: Mass Media, local authorities,health professionals, professionals of the private sector (i.e. pharmacists,lawyers, personnel of tourist enterprises, banks’ personnel) and services of the

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public sector (i.e. Greek Police, Military Force, Greek Mail Services, GreekTelecommunications Organisation, Public Electricity Agency).

Information and sensitisation of employees and employers on health issues aswell as on drug and alcohol prevention are the main objectives of all respectiveinterventions. Moreover, the programmes carried out at local level aim atprofessionals’ actualisation and involvement in community preventionprogrammes, so as for a local prevention network to be established. Manyprevention interventions at the private sector, the media and the police andmilitary services are organised after the sensitisation of the wider community bythe prevention centres. Trade unions, also, provide the impulse for preventionprogrammes at their workplace to be implemented.

Evaluation of prevention initiatives at the workplace is quite limited. However,interventions at professionals and agencies at the local level as well as thoseaddressing police officers and military services are systematically evaluated.Process evaluation for interventions at the military services has shown that theextremely large number of participants and the obligatory attendance to theseminars prohibit active interaction and integration of information. Moreover,outcome evaluation of a prevention programme that addressed police officersindicated that 90% of them accepted the importance of prevention as well asthat they could play a significant role in preventing drug use/abuse.

Finally, the Drug Dependence Prevention & Health Promotion Centre«PYXIDA» has implemented since 1998 a prevention programme that wasaddressed to professionals and agencies from different fields. According to theevaluation results after a two-year implementation of the programme,participants appeared to be sensitised to the psychosocial factors that lead todrug use/abuse and to the importance of volunteers’ role in prevention. Thelatter was proved by the fact that many of the participants decided to form agroup of volunteers, which has already taken action on organising variousprevention activities with the aim to inform and sensitise the local community(see also Chapter 9.1.4 Community Programmes).

9.6.5 Ethnic minorities

Although a great number of immigrants and refugees came in Greece duringthe last decade, no specialized treatment programmes for this population havebeen developed yet. However, an increasing number of prevention programmesaddresses minority groups and socially excluded people, while manysensitization activities take place, under the initiative of therapeutic programmesand volunteers associations.

The Hellenic Centre of Intercultural Psychiatry and Care continued itsprogramme entitled “Combatting social exclusion in the context of substanceabuse”, which is implemented since 1996 (see also 1998 Annual Report). Theobjectives of this programme are the following: a. information and sensitizationof the local and mainly of the school community on prevention of drugdependence and on promotion of health, b. social rehabilitation and vocational

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guidance of adolescents belonging mainly in socially excluded groups, and c.research on mobile populations and on socially and culturally differentiatedgroups, especially in terms of their attitudes towards health issues.

In 1999, the local communities where the programme is implemented requestedfrom the Centre to address 8,000 students, parents and teachers. Afterchoosing the most vulnerable and problematic groups, the Centre trained 100teachers, it sensitized 300 parents and it intervened in 250 secondary studentsof high-risk. Moreover, the Centre assisted 250 socially excluded families intheir contacts with public services, while it provided the following services: a.material support to 120 families with serious survival problems, b. counsellingand/or psychiatric support to 70 persons, c. vocational guidance to 35 persons(20 male adolescents and 15 women aged 18-25 years old), and d. workshopson creative occupation to 100 children outside school as well as to women aged15-35 years old. A subsidized training seminar was also organized for 20unemployed ROMs in co-operation with the National Organization of Welfare.

According to the evaluation results, the programme contributed to severalpositive developments in micro and macro level. In particular, the successfulcooperation between the prevention agents and the local community assisted inthe effective exchange of information, while the residents changed theirattitudes towards the social welfare services, which resulted to an increasedaccess to them. In macro-level, the programme promoted the development ofnew social structures and networks, which aim at improving the living conditionsfor socially excluded and minority groups.

The Information & Prevention Centre Against Drugs of the Municipality ofXanthi – a region where many people from the Muslim minority live – organizedin 1999 an educational seminar on health promotion issues. The group of thetwenty participants consisted of Christian and Muslim teachers of secondaryeducation. Also, the four Drug Prevention Centres of Attica address theirservices to minority groups living in the wider area of Athens, aiming to reducefactors leading to social marginalization and exclusion.

An initiative of high importance in 2000, was a two-day happening of culturalactivities, organized in Athens by the KETHEA therapeutic programme“DIAVASSI” in cooperation with nine volunteers associations. This happeningaimed at sensitizing the wider community about the effects of social exclusionon individuals’ well being and on the quality of interpersonal relationships. Drugusers and cultural minority groups jointly undertook the various culturalactivities, through which the message of cooperation among the differentsocially excluded groups despite their differences was conveyed.

Apart from prevention and sensitization interventions, research studies onminorities were also developed. In the context of the postgraduate courseentitled “Social Exclusion and Minorities” of the Panteion University in Athensseveral studies were conducted in 2000 regarding the issue of minorities anddrugs. Their findings will be available at the beginning of next year.

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Despite the fact that no specialized treatment programmes for minority groupsare available, immigrants or people belonging to different cultures are able toask for drug therapy at the existing treatment services. Results from the twosubstitution programmes in Athens showed that 5% (10 persons) of their clientswere not Greek (Douzenis et al. 2000). In particular, two of them were E.U.citizens, one was from the former Soviet Union and the rest were ROMs. Out ofthe ten clients being from different cultures, only four remained in treatment.Cultural differences appear to be the main reason for the high percentage ofdropouts from treatment by drug users belonging in minority groups. Similarfindings have been reported from KETHEA therapeutic programmes, whereculturally different clients have been increased during the last years. Forexample, the number of people from minority groups, who asked for therapy atthe therapeutic programme for adolescents “STROFI” in 1999, was fourfoldcompared to 1998 (STROFI 2000).

In order to respond to minorities’ needs more effectively, KETHEA plans todevelop in the near future a specialized therapeutic programme entitled“Transitional Integration Centre of Special Social Groups”. This Centre willinclude streetwork interventions in the Athens greater area, a counsellingprogramme aiming at psychosocial support, a hostel and a drug-freetherapeutic programme. Moreover, it will provide training to professionalsbelonging in ethnic minorities in order for them to work in the Centre and it willcooperate with other health and social agencies, so as for a support network tobe established (Poulopoulos in press).

9.6.6 Self-help groups

Narcotics Anonymous (NA) is an international, non-governmental organizationaddressed to both men and women drug users, with the only requirement forthem to wish to stop taking drugs. Apart from the support groups addressed todrug users, NA also organizes open meetings for the lay public.

Regarding the evaluation of their interventions, this is difficult to be conducted,since they do not keep records with their members. However, an indicator ofpositive value is the fact that the number of the drug users who participate in theNA groups is constantly increased at annual basis.

Self-help groups are also organized for youth at risk and for experimenting drugusers by the “Hellenic Church Mission of Support to Socially Excluded and DrugDependent Persons”. This mission, which is implemented by young former drugusers, includes streetwork interventions in Athens, Thessaloniki and Patras andit also provides counselling services.

9.6.7 Alternatives to prison and prosecution

Pecuniary penalties and confinement in specialized treatment prison units afterthe offender’s acquiescence are the alternatives to prison for drug law

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offenders. The first specialized detoxification unit for drug dependent prisonerswill be inaugurated in Thiva (Central Greece) in the near future.

Moreover, the Minister of Justice has planned a pilot programme providingamong others for the entering into force of inactive legal provisions alternativeto prison, such as labour of public benefit.

Prosecution alternatives are decided by the Public Prosecutor’s office, which incase of drug addicted offenders can decide for: a. the confinement of theoffender in a specialized treatment prison unit as alternative to time spent fortemporary detention or serving of a sentence, and b. the permanentpostponement of penalty imposition in case the offender is attending a legaldetoxification programme.

10. QUALITY ASSURANCE

10.1 Quality assurance procedures

The promotion of quality at the demand reduction field, especially at theprevention centres, was the first and foremost priority in 2000. Formalrequirements for quality assurance in the prevention programmes had beendevised since 1996, when the first prevention centres were established by theOKANA in co-operation with the local authorities. However, practical difficulties(i.e. bureaucracy) or lack of sufficient support, resulted to considerabledeficiencies at the implementation of the prevention programmes and impairedthe quality of the provided services. With the aim to ameliorate this particularsituation and to ensure quality and effectiveness of prevention interventions,policy makers re-formulated in 2000 a comprehensive statutory framework withspecific criteria and requirements.

In particular, the current formal requirements can be classified in six majorcategories, as follows:

• Number and professional background of the prevention centres’ personnel

• Qualifications that prevention agents should have in order to be adequateenough to implement quality prevention programmes

• Systematic participation in training programmes, which will be organized byspecialized institutions

• Evaluation of all prevention interventions

• Continuous supervision of the prevention centres and co-ordination of thelocal authorities in their role to ensure their development

• Active and systematic co-operation among all prevention centresnationwide.

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Each of these requirements consists of various criteria, which are portrayed indetails on Table 18.

The primary rationale of the specific criteria, presented on Table 18, is based onthe initial policy plan concerning prevention centres, which was formulated in1996, as already being said. However, their precise conceptualization stemsfrom the existing difficulties and needs that prevention centres stated at arelevant evaluation study (see Chapter 10.2 Evaluation).

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Table 18: Specific criteria in the prevention field according to theformal requirements for quality assurance

FormalRequirements

Specific Criteria

Preventionagents’ numberand background

- Each prevention centre’s personnel should consist of fiveprofessionals at least: one Scientific Director, three morescientists and one secretary.

- The background of the scientific group should be related tohuman and/or social studies, with one person at least beingPsychologist.

Preventionagents’

qualifications

- All prevention agents should have a Bachelor’s degree inPsychiatry, Psychology, Sociology, or in Social Work.

- Preference is giving to those having Master’s degree, previousemployment in prevention or therapeutic agencies, training in aspecific psychotherapeutic method, training in prevention (atleast 100 hours) and good knowledge of a foreign language.

- The scientific director should further have a three-yearprevious experience in prevention or therapeutic programmesor a five-year one in their specialty.

Training

- All prevention agents should participate in a three-monthtraining programme, which aims at promoting a commonphilosophy and methodology in the prevention field nationwide.

- Continuous participation in training seminars, which concern:a) implementation of existing and new educational materials,b) planning and development of interventions in specificpopulations (i.e. army), and c) self-evaluation.

- Co-ordination of all the training agencies by a central body, soas overlaps and confusion to be avoided.

- Development of new educational materials, so as preventionmethods and interventions to be enriched.

Evaluation

- Prevention centres should evaluate internally the whole rangeof their interventions as well as their three-year work plan.

- Training agencies should provide prevention centres with thenecessary scientific instruments and know-how for theevaluation purposes.

- Training institutions will be also evaluated for the quality andeffectiveness of their programmes.

- External evaluation of the prevention programmes isenvisaged in the near future.

Supervision ofprevention

centres and co-ordination of

local authorities

- A central co-ordination body should systematically implementa two-way supervision schema: supervision of the preventionwork from planning to outcome and supervision of the localauthorities’ role in supporting and funding prevention centres.

- Continuous monitoring and immediate response to theprevention centres’ difficulties and needs.

Co-operation- All prevention centres should have access to the Internet.

Electronic chat groups and databases with information onprevention programmes will be provided soon and preventioncentres should use them.

- Prevention agents should participate in meetings andconferences so as to exchange experience.

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Besides the training institutions, which are responsible for supporting preventioncentres in educational and scientific issues, the OKANA as the central co-ordination body on drugs and the Greek REITOX Focal Point will be expected toplay a crucial role in monitoring and assessing quality of the preventionprogrammes.

The following instruments are those currently applied in quality assurance at theprevention field:

• The “Exchange on Drug Demand Reduction Action” (EDDRA) questionnaire

• Evaluation questionnaires included in the educational packages, which areused at school and family prevention programmes

• Evaluation standardized instruments as well as self-constructedquestionnaires by the prevention centres

• Annual reports submitted to the OKANA

• Feedback that is provided in meetings between prevention agents, traininginstitutions and supervising bodies.

The current situation in the treatment field is quite different from the one existingfor the prevention centres. In particular, a single homogenous schema forquality assurance in drug therapy has not been implemented yet. This is due tothe fact that priority was given to prevention centres on the one hand, and onthe other because treatment programmes differ substantially in terms of theirphilosophy, theoretical principles, therapeutic methods and organizationalframework. Thus, the establishment of common formal requirements for qualityassurance in this field appears to be a rather perplexing task.

However, with the opportunity of the Workshop on “Evaluation of PsychoactiveSubstance Use Disorder Treatment”, organized by the WHO, the OKANA andthe Greek Focal Point in March 1999, a provisional national plan for evaluatingtreatment services was structured for the first time (Chart 1). This plan has beenformulated according to the Guidelines of the WHO/UNDCP/EMCDDAWorkbook series and the majority of the therapeutic programmes approved it.Although it has not been implemented in practice yet, this plan constitutes aformal common basis for future action.

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Chart 1: Provisional National Plan for the Evaluation of Treatment Services

Components:

Core activities:

Short-term objectives:

Medium-termobjectives:

Long-term objectives:

Promoter(OKANA, F.P., Others)

Partners (Ministry of Health,OKANA, TherapeuticProgrammes, NGO’s)

Scientific and TechnicalInfrastructure

Proposal preparation(Rationale)

- Debate- Consultation

- Framework of implementation

Scientific and TechnicalFramework

- to sensitize- to stimulate involvement

- to ensure commitment- to promote co-operation- to ensure means, funds

- to sustain & promoteevaluation

- external evaluation

- to seek general improvement of quality- to assess cost-effectiveness

- to improve the overall plan of treatment in terms of needs,community and treatment policy

- to meet drug users’ needs more effectively- to ensure funding

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At the present, each specialized therapeutic agency has developed their own specificprinciples, criteria and instruments for quality assurance of their services. Still, all ofthem should comply with the following minimum requirements:

• To maintain and to provide a comprehensive and clearly defined framework oftreatment services, which must function under law permission.

• To occupy specialized and highly trained personnel or former drug users withadequate prior education in counselling/treatment issues

• To actively care for the continuous improvement of their services throughparticipation in national and international training programmes, conferences andseminars

• To participate in or to conduct research studies relevant to treatment issues

• To keep records for their clients’ drug use patterns and their socio-demographiccharacteristics and to monitor their psychosocial development. When requestedby policy makers or research institutions, to distribute the data available regardingeither their clientele or their programmes.

• To be supervised by the Organization Against Drugs (OKANA), except ofKETHEA’s treatment programmes.

Optimally, treatment agencies should also conduct internal or external evaluation oftheir services on a constant basis. However, several discrepancies exist on theextent and the type of the evaluation studies as well as on the methodology usedamong the various treatment agencies.

10.2 Treatment and prevention evaluation

Two major initiatives played a crucial role in promoting evaluation at the drugdemand reduction field in 1999-2000. The first one was the WHO Workshop on“Evaluation of Psychoactive Substance Use Disorder Treatment”, which was held inMarch 1999. The second was a national evaluation study, conducted from December1999 to February 2000, on the difficulties and needs of the forty prevention centresthat had been founded by OKANA up to the beginning of the study. These two eventsconstituted the basis for a policy on evaluation to be planned – in the case oftreatment programmes - or to be implemented in the case of prevention programmes(see also Chapter 10.1 Quality assurance procedures).

The evaluation study carried out by the OKANA and the Focal Point at the preventioncentres nationwide, was aiming at: a) assessing the various difficulties in planning,implementing and evaluating primary prevention programmes, b) determining thereasons for the existence of these problems, c) reporting the educational andscientific needs of the prevention agents, and d) detecting possible solutions forovercoming the existing difficulties. Two self-constructed questionnaires with closedand open questions were administered to the prevention agents group and to thepresident of the local authorities board of each prevention centre.

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According to the findings of this study (Paralaimou et al. 2000), some of the maindifficulties that prevention centres confront concern the following:

• the lack of funding and support by the local authorities, which mainly stems fromtheir lack of sensitization in the importance of prevention centres’ role at the localcommunities

• the insufficient co-operation between the OKANA and the prevention centres,which appears to result from the decreased number of OKANA’s personnel andfrom the existing bureaucracy

• the difficulty prevention agents have to put in practice what they have beentrained in

• the lack of training and of experience in the implementation of evaluation studies.

Regarding evaluation, 64.7% of the thirty-eight prevention centres, which participatedin the study, reported that they have difficulties in conducting evaluation of theirprogrammes. More specifically, lack of adequate training and expertise wasmentioned by nearly the majority of the centres as the main difficulty in conductingthe three types of evaluation: planning evaluation (76.9%), process evaluation(77.8%) and outcome evaluation (40.0%).

On the grounds of these findings, a concrete and methodical evaluation policy startedto be implemented. Training in self-evaluation has been posed as the first priority.Specific institutions with prior experience on the issue (i.e. Educational Centre for thePromotion of Health and the Prevention of Drug Abuse) were assigned to beresponsible for prevention agents’ evaluation training. This will be organized on acontinuous basis with emphasis on regular mutual feedback and adequate responseto the current needs. Moreover, OKANA has systematized, through the upgradedresponsibilities of a scientific committee, the supervision processes regarding theperformance of the prevention centres and the role of the local authorities. Finally,initial efforts (i.e. ensuring funding and employing personnel) were made for externalevaluation to be put on.

The University Mental Health Research Institute (UMHRI) in co-operation with theDirectorate of Secondary Education of the Prefecture of Ahaia conducted anotherstudy in 1999-2000 in the context of evaluation research. The aim of this study wasto measure the outcome of the health promotion programmes in schools dealing withdrug prevention issues, which were implemented in the region within the academicyear 1997-1998. The sample of the study included 500 students of the fifth and sixthgrade of the high schools where the health promotion programmes wereimplemented and a control group. The tools used were the ESPAD questionnaire anda specially designed questionnaire for teachers’ opinion. The findings of this studywill contribute to possible changes and modifications to the health promotionprogrammes that are implemented nationwide by the Ministry of Education.

Although an evaluation policy in the treatment field was planned in 1999, it has notbeen implemented yet (see also Chapter 10.1 Quality assurance procedures).Nevertheless, the WHO Workshop on Evaluation of drug treatment contributedconsiderably to promoting evaluation of therapeutic programmes. In particular, threetherapeutic agencies initiated evaluation interventions after the Workshop, according

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to the specific methodology proposed in the Workbook series. Moreover, theWorkshop advanced the evaluation processes already implemented by sometherapeutic programmes through their modification and enrichment.

Evaluation practice in drug treatment services appears, though, to be ratherfragmented and unmethodical. With the opportunity of the WHO Workshop and of thetentative “National Plan for the Evaluation of Treatment Services”, representatives ofall the treatment agencies nationwide agreed that in order for a comprehensive andsystematic treatment evaluation to be implemented, the following requirementsshould be covered:

• to ensure funding for evaluation purposes

• to precisely define the co-ordination, planning and implementation procedures inorder for a global evaluation schema to be implemented in all treatment agencies.This determination should be made either by a central co-ordination body (i.e.OKANA) and/or in co-operation with the treatment institutions.

• to clarify the objectives of such a national common evaluation policy as well asthe means the evaluation results will be used, so as to be of the treatmentagencies’ benefit

• to promote training in evaluation issues, which should be organized on asystematic basis and within a comprehensive and specific scientific framework.

Indeed, training in treatment evaluation is scarce and unsystematic. Apart from theWHO Workshop on “Evaluation of Psychoactive Substance Use Disorder Treatment”,which was organized by the OKANA and the Focal Point, the only other educationalprogramme developed in 1999 was the one called “Social Planning and SocialPolicy”. This programme, which is co-ordinated by the Therapy Centre for DependentIndividuals (KETHEA) in co-operation with the Social Policy Department of theBoston College, aims at assisting participants in planning, implementing andevaluating comprehensive action plans. However, a growing interest in treatmentevaluation training is exhibited through the organisation of relevant conferences (i.e.“Evaluation of drug treatment agencies”).

The KETHEA is the only therapeutic agency that conducts systematic evaluation ofits services on a regular basis. This is done both internally and externally. Theinternal evaluation is based on the Management Information System, which collectsclinical, administrative and financial data on a monthly basis across KETHEA’sprogrammes nationwide, and on the Continuous Improvement Quality Tool that isimplemented on an annual basis. A committee of three experts does the externalevaluation. The external evaluation includes: a) questionnaires administered to drugusers and their families, b) focus group interviews among members of the personnel,drug users and their families, c) interviews with employees and drug users, and d)participant observation of the experts committee. The satisfaction of the providedservices, the effectiveness of the treatment programmes, ethical aspects and thesafety and hygiene in treatment centres are some of the main issues that are underthe scope of external evaluation (KETHEA 2000).

In 1999-2000, the KETHEA was also active in conducting research studies related toevaluation issues in the prevention and the treatment field. General principle of these

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studies is to make the best possible use of their results so as to improve the qualityof the provided services, but also of the research methods per se (see also Chapter10.3 Research).

10.3 Research

Research in the demand reduction field is continuously developing, on the grounds ofthe necessity to support prevention and treatment interventions upon specificresearch findings. Still, research in the treatment domain is more developed incomparison with the existing situation in the prevention field. This is mainly due to thefact that prevention centres have been established recently (i.e. within the last fouryears) and because priority was given to the implementation of preventionprogrammes at the local communities rather than to researching. However, a growinginterest in conducting prevention research studies has been observed in 1999-2000.Moreover, special attention was paid on evaluation projects regarding treatmentprogrammes.

The objectives, structure and other information about the research projects that eitherstarted or were in progress in 1999-2000 are presented below. They are classifiedaccording to the three levels of prevention (primary, secondary and tertiary), whereasevaluation studies are portrayed in a distinct category.

Research projects in Primary Prevention

1. “Pilot study on the cross-sex relations in fourth grade high-school students”(1998-2000)

Research Agency: The “PROTASI” Movement in collaboration with theDirectorate of Secondary Education, The Athenian Center of Study of the HumanBeing (AKMA) and the University of Patras

Sources of Funding: Ministry of Education (Health Promotion Department) and theNational Institute of Youth

Objectives: To explore students’ needs regarding cross-sex relations and sexeducation issues, aiming at a more comprehensive implementation of the relevanthealth promotion programmes

Sample: 278 fourth grade high-school students from two schools of the Prefectureof Ahaia.

Method: Questionnaires.

2. “Survey on the social needs of young people who live in the region of the CreativeOccupation Center of the “PROTASI” Movement: The need to establish and tosupport a Youth Café” (1999-2000)

Research Agency: The “PROTASI” Movement in collaboration with the CreativeOccupation Center

Objectives: to explore the young people’s leisure-time activities and to detect theirbeliefs, in order for the Youth Café to be not only a meeting-point but also a placewhere they could develop creative activities that will meet their needs

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Sample: Young people aged 16-25 years old from the region, representatives oflocal agencies, key-persons of the district, members of the “PROTASI” Movementand members of the Creative Occupation Center aged 13-17 years old

Method: Participant observation, semi-structured interviews with representativesof local agencies and questionnaires administered to the other subjects of thesample.

3. “Research on the use of addictive substances among the students population ofthose prefectures where Prevention Centres are established by the OKANA”(1999-2000)Research Agency: University Mental Health Research Institute (UMHRI)Sources of Funding: The Organisation Against Drugs (OKANA)

Objectives: To study the prevalence of the addictive substances use among highschool students as well as the related psychosocial factors, in 26 prefectureswhere Prevention Centres operate. Research data will assist prevention agents toplan their interventions in more accordance with the local needs.

Sample: A representative sample of high school students (i.e. fourth and fifthgrade) from each prefecture, which will constitute 5.000 subjects overall.

Method: The European questionnaire of the ESPAD study, translated andadapted in Greek.

Research projects in Secondary Prevention

1. “Substitution Therapy in the EU” (1999)

Research Agency: The OKANA in collaboration with the ObservatorioEpidemiologio Regione Lazio (Italy) and the National Addiction Center (UK)Sources of Funding: The European Union and the OKANA

Objectives: Description of the substitution programmes that are beingimplemented in the EU countries and review of the related literature

Sample: Substitution Units of the OKANA.

2. “Drug use among prisoners” (1999)Research Agency: The OKANA in collaboration with the Ministry of Justice

Sources of Funding: The European Union and the OKANA

Objectives: To collect up to date information regarding drug use among prisonersin order to plan new effective policies in prisons about: a) drug demand reductioninterventions, b) harm reduction programmes, c) promotion of a healthy way ofliving, and d) training of prison’s personnel. Research data will also assist in re-examining the current legislation regarding possession and abuse of illegal drugs.Method: Administration of questionnaires to prisoners and to prison’s personnel.

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3. “Study on the intravenous drug use – Phase B”Research Agency: The OKANA and the WHO.

Sources of Funding: The OKANA and the WHO.

Objectives: To promote harm reduction from the intravenous use of psychoactivesubstances.

Sample: 400 drug users (200 users who were admitted in a therapeuticprogramme within the last 30 days and 200 street-users).

Method: Administration of questionnaire.

4. “Socio-demographic characteristics and patterns of drug use among those drugusers who approached the KETHEA’s Counselling Centers from 1995 to 1999”(1999)Research Agency and Source of Funding: KETHEA

Objectives: To compare the last five-years’ data, in order to detect new trends ofdrug use and changes in the socio-demographic characteristics.

Sample: Drug users who applied for therapy in the KETHEA’s CounsellingCenters from 1995 to 1999.

Method: Interviews based on the “First Treatment Demand Indicator” (PompidouGroup).

5. “Socio-demographic characteristics and patterns of drug use among those drugusers who approached the KETHEA’s Counselling Centers in 1999” (1999-2000)Research Agency and Source of Funding: KETHEA

Objectives: To explore the needs of drug users who seek help and to improve theprovided services.

Sample: Drug users who applied for therapy in the KETHEA’s CounsellingCenters in 1999.

Method: Interviews based on the “First Treatment Demand Indicator” (PompidouGroup).

Research projects in Tertiary Prevention

1. “Research on the dimensions of social exclusion” (1999-2000)

Research Agencies: The KETHEA and the CEIS (Italy) in collaboration with thePrivatklinikkey Gundderuplund (Denmark) and the Warwickshire ProbationService (UK).Sources of Funding: The European Union and the KETHEA.

Objectives: To investigate the factors that associate drug addiction with exclusionfrom the labour market and with social exclusion, in order to develop effectivemethods for their combating as well as networks for drug users’ reintegration.

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Sample: Three different groups of 75 drug users from each participant country(Greece, Denmark, Italy, UK). The three groups are: a) drug users who had a joband they lost it because of their dependence, b) drug users with delinquentbehaviour, who are socially excluded, and c) parents and relatives of the secondgroup.

Method: The qualitative method of “life stories”.

Prevention and Treatment Evaluation Studies

In addition with the two evaluation studies regarding prevention centres and healthpromotion programmes conducted in 1999-2000 (see Chapter 10.2 Treatment andPrevention Evaluation), the following evaluation projects were also done:

1. “Evaluation of the pilot health promotion and prevention programme in the UnifiedMulti-field High School of Piraeus” (1997-1999)Research Agency and Source of Funding: KETHEA

Objectives: To evaluate the results and efficacy of the programme and to makesuggestions for the implementation of similar programmes in the future.Sample: High school students and their teachers

Method: a) questionnaires in experimental and control groups (pre-test, post-testmethod), b) two focus-groups, one with students and one with teachers, c) diaryof the programme, and d) the Greek version of the “STEPP” instrument(“Staff/Team Evaluation of Prevention Programmes”, U.S. Department of Healthand Human Services, Rockville, Maryland 1987).

2. “Evaluation of the pilot health promotion and prevention programme in the 28th

Primary School of Piraeus” (1998-1999)Research Agency and Source of Funding: KETHEA

Objectives: To evaluate the results and efficacy of the programme and to makesuggestions for the implementation of similar programmes in the future.Sample: High school students and their teachers and parents.

Method: a) questionnaires, b) focus groups with parents and teachers, c) diary ofthe programme, and d) students’ papers.

3. “Outcome effectiveness research of the KETHEA’s therapeutic communities”(1999-2001)

Research Agency: The KETHEA and the Department of Sociology of the HellenicNational School of Public Health in collaboration with the University ofPennsylvania (U.S.).

Objectives: To evaluate the effectiveness of the therapeutic programmes and tolocate the parameters that enhance the therapeutic result.

Sample: 500 individuals who spent even one day in the KETHEA’s therapeuticcommunities from 1994 to 1995.

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Method: Field-study based on semi-structured and in-depth interviews.

4. “Clients’ satisfaction from the services of KETHEA” (1999-2000)

Research Agency: The KETHEA in collaboration with the Department ofSociology of the Boston College (U.S.)Objectives: To improve the policy and the provided services of the KETHEA.

Sample: The total number of clients (1328 individuals) who were in the treatmentservices of KETHEA for at least a limited period of time.

Method of Data Collection: Self-administered questionnaire.

Apart from the above research projects, a study of special interest is the oneconducted by the Physiology Laboratory of the Medical School of the University ofIoannina in collaboration with the Drug Dependence Treatment Unit (PsychiatricHospital of Thessaloniki) and the Counselling Centre for Combating Drugs ofIoannina. According to the results, when heroin users who are under the withdrawalsyndrome are provided with large quantities of Vitamin C, withdrawal symptomseither do not develop or they decrease considerably. On the grounds of thesepromising findings, the research team suggested that Vitamin C could replace thedrugs currently prescribed for combating the withdrawal syndrome.

As it may have become obvious from the information previously provided regardingthe current demand reduction research projects, the relations between research anddrug services are robust and reciprocal. In many cases, the research projects areundertaken by the drug services in collaboration with national or internationalresearch institutions, so as to ensure the scientifically sound methodology anddevelopment of the study. On the other hand, when research agencies areresponsible for conducting demand reduction studies, these are always done in closeco-operation with drug prevention or treatment programmes. This kind of co-operation between research and drug services prevail not only because it is easy tofind the samples of the studies (i.e. drug users) at the drug services, but alsobecause it appears to have been acknowledged that research findings contribute tothe improvement of the drug services. However, co-operation between researchersand health professionals in the drugs field needs to be further reinforced.

The latter is also proved by the fact that many research projects are funded by thedrug services themselves (i.e. KETHEA). Other sources of funding are nationalgovernmental and non-governmental bodies (i.e. Ministry of Education, NationalInstitute of Youth, OKANA), international organizations (i.e. WHO) and the EuropeanUnion. The amount spent on research by the OKANA in 1999 was 130.000 Euro.However, a global estimation on the amount spent on research by the differentsources at the national level is not available yet. In order to fill these gaps ininformation provision and to promote exchange of experience in the research field,the Greek Focal Point has developed a relevant electronic database, which will startto operate at the beginning of 2001.

There are two types of training in demand reduction research: a) seminars organizedby national or international research institutions to professionals in the drug field, for

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the purposes of a particular study to be conducted, and b) in-service trainingaccording to the needs of the drug agency. Nevertheless, training in demandreduction research is rather unsystematic and it appears that it is up to the drugservice’s willing to have training in research methods or not. Work overload from thetherapeutic or prevention tasks, lack of time and feelings of inadequacy regardingprevious knowledge of research methodology are the main obstacles that impedeprofessionals from the drug field to get trained in demand reduction researchmethods. Thus, it seems necessary to develop a certain policy that will promotetraining in demand reduction research on a regular basis, which will consequentlyadvance research in the demand reduction field.

10.4 Training for professionals

On the grounds of the promotion of quality assurance in the prevention field, trainingof prevention agents acquired a clear and concrete structure. Based on the results ofthe national evaluation study at the prevention centres and on the institutions’previous experience in training programmes, the OKANA as the central supervisingbody of all prevention centres nationwide, defined which institutions will provideformal training in the prevention field and what type of training will be provided byeach (Table 19: Structures and types of training in the prevention field).

In this vein, the Educational Centre for the Promotion of Health and the Prevention ofDrug Abuse, which has a great experience in educating prevention agents, plays amain role in organizing training on a systematic basis, in co-operation with the otherinstitutions that are delineated in Table 19. Apart from these institutions, other localeducational agencies may also provide training services, unless overlapping ispossible. In general, training focus on the three following aspects: a) self-evaluation,b) adaptation of a holistic prevention approach involving all sectors and social groupsof the local communities, and c) implementation of new educational materials anduse of new techniques.

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Table 19: Structures and types of training in the prevention field

Training institutions1 Types of training

Anthropos Athenian Institute(AKMA)

Application of systemic theory and methods in theprevention field

Department of Adolescentsand Young Adults – DrugDependency Unit “18 ANO”

• Planning and implementation of schoolprevention programmes at the local community

• Application of short-term secondary preventiontechniques to drug users and their families

Educational Centre for thePromotion of Health and thePrevention of Drug Abuse

• Three-month introductory training in preventionissues

• Planning and implementation of school,community and family prevention programmes

• Planning and implementation of preventionprogrammes to specific target-groups (i.e. army,ethnic minorities, primary school children), in co-operation with other training agencies

• Implementation of specific educational materialsproduced by the Centre

• Self-evaluation of prevention interventions and ofthe three-year prevention work

Greek REITOX Focal Point

• Filling in the “Exchange on Drug DemandReduction Activities” (EDDRA) and make gooduse of it in the prevention work

• Evaluation methods and techniques

Hellenic Centre forIntercultural Psychiatryand Treatment

Planning and implementation of preventioninterventions to ethnic minorities and to culturallydifferent people

Human Relations ResearchLaboratory (EDAS)

Application of systemic theory and methods in theprevention field

Therapy Centre forDependent Individuals(KETHEA)

• Implementation of the educational material “Skillsfor the Primary School Child”, published by theCentre

• Application of short-term secondary preventiontechniques to drug users and their families

University Mental HealthResearch Institute (UMHRI)

Application of research methods in the preventionfield within the framework of specific studiesconducted by the Institute

1 Training institutions are presented in alphabetical order.

A great number of new educational materials were published in 1999-2000 not onlyconcerning prevention issues, but also regarding various aspects of drug abusetreatment. In particular, the Educational Centre for the Promotion of Health and thePrevention of Drug Abuse produced the following information material and trainingpackages for professionals working at the prevention field:

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• “Children’s games” (2000): This book is provided to primary school teachers and itis a translation of a Swiss educational material addressed to children aged 7-9years old. The main subject is the conflicts that children of that age experience atcognitive, emotional and interpersonal level.

• “Adolescents’ chats: Mental Health and Interpersonal Relationships” (2000): Itwas produced on demand of the Ministry of Education. It is addressed tosecondary school teachers who implement health promotion programmes at theirschools and to prevention agents working with adolescents aged 15-18 years old.

• “A ship’s diary – Armenistis 1900” (2000): It is used by prevention agents whoimplement youth prevention programmes outside schools. It aims at assistingadolescents in the process of autonomy.

• “Elements related to the addictive substances” (2000): This book is addressed toparents and teachers who participate in health promotion programmes regardingdrug prevention. It provides basic information about the addictive substances(legal and illegal) as well as about the prevalence of drug use in Greece and thecurrent law on drugs.

Moreover, the KETHEA translated in Greek the “Drug Education for YoungOffenders” (TACADE) and it published the “Mental Health and InterpersonalRelationships” manual in collaboration with the Mental Health Organization forChildren and Adolescents. This manual addresses students aged 11 to 14 years old.The “Addiction Counselling Competencies: The Knowledge, skills and attitudes ofprofessional practice” was another publication of high importance, since a two-yeartraining programme run by the KETHEA in collaboration with the University ofCalifornia, is based upon this material. 52 professionals from the prevention and thetreatment field have been trained up to now at this programme, while 50 more willparticipate from 2000 to 2001.

Further training programmes organized by the KETHEA in 1999-2000 are thefollowing: a) “Relapse Prevention”, in collaboration with the Addiction ResearchInstitute, b) “Introduction to groups”, in collaboration with the Department ofCommunication and Mass Media of Athens University, and c) Vocational training andcounselling of former users (KETHEA 2000). Additionally, the Greek Focal Pointorganize on a systematic basis training programmes in the implementation of the“First Treatment Demand Indicator”, the “European Addiction Severity Index”(EuropASI), the “Exchange on Drug Demand Reduction Activities” (EDDRA) and the“Treatment Unit Form” (TUF).

Despite these efforts to promote training programmes for professionals working atthe treatment field, the main direction currently is towards in-service training, whichhowever is rather fragmented. In order to systematize training in the treatment field,the OKANA plans the regular organization of seminars for therapeutic agents as wellas the education of doctors and psychiatrists in drug treatment issues. Moreover,within the next three years (2000-2003) the OKANA plans in co-operation with theMinistry of Education to introduce courses on prevention and treatment issues in theUniversity schools of education and of health (OKANA 2000). Nowadays, the onlyavailable University education in drug-related issues is the two-year postgraduatecourse offered by the Psychology Department of the University of Thessaloniki. Also,

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those University students of social sciences who are in the last year of their studiesand who wish to have such training are able to get a six-month practical training attherapeutic agencies.

Evaluation of training programmes is mainly oriented on impact data (i.e. number ofparticipants) and on qualitative information regarding process and organizationalaspects. Thus, results on the efficacy of the programmes and statistical findings arequite limited. The Educational Centre for the Promotion of Health and the Preventionof Drug Abuse, the Greek Focal Point and the KETHEA systematically conductsevaluation of their training programmes.

The Educational Centre for the Promotion of Health and the Prevention of DrugAbuse has trained up to now 203 prevention agents, most of whom are occupied atthe municipal prevention centres. Also, it has trained 56 professionals, who work atthe health promotion programmes organized by the Ministry of Education and 138other professionals (police officers, lawyers, etc.). Evaluation results showed thattraining in specific educational packages and the practical application of theories aremore effective than theoretical training in general prevention principles andtechniques. Moreover, most of the participants mentioned that training assisted themin being able to implement prevention programmes, but they asked to havecontinuous supervision during the implementation of the educational materials.

The Greek Focal Point evaluated in 1999-2000 the WHO Workshop on “Evaluation ofPsychoactive Substance Use Disorder Treatment” (see Chapter 10.2 Treatmentand prevention evaluation) and the two seminars on the EuropASI questionnaire.According to the evaluation results of the training on the EuropASI, most of theparticipants valued the use of the specific instrument for research and evaluationpurposes and they expressed their willing to administrate it on a systematic basis.Indeed, the EuropASI was administered after the training in all treatmentprogrammes, representatives of which participated in the seminars. However, all ofthem mentioned that the training would be more effective if it lasted for more than twoconsecutive days. Finally, in 1999 the KETHEA designed and implemented aquestionnaire to evaluate the results and efficacy of the two-year training programmeentitled “Addiction Counselling Competencies: The Knowledge, skills and attitudes ofprofessional practice”.

11. CONCLUSIONS: FUTURE TRENDS

Based on the evolution of new interventions and programmes as well as on thenational policy on drugs suggested by the OKANA in 2000, the main future trendsidentified are as follows:

• Drug-free programmes for adult drug users will be expanded nationwide with theaim to cover the existing lack of therapeutic options at the local and regional level.

• New multi-phase programmes aiming at adolescents and young adults will bedeveloped, which will complement the work of primary prevention centres.

• Substitution and maintenance units will be further expanded, with the result forthe number of drug users in the waiting lists to be decreased.

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• Specialised programmes for high-risk groups, such as immigrants and prisoners,will be implemented, in order to provide these groups with adequate and adjustedto their needs services..

• Vocational training and after-care services will become of higher importance andthey will be enriched.

Apart from these trends that have emerged already, it appears to be necessary foroutreach and low threshold interventions to be further developed, in order to becomeeasier for drug users to establish initial contact with mental and health services.Special emphasis should also be given in the development of demand reductioninitiatives within prisons, which currently are quite limited. Moreover, it seemsimportant for primary prevention interventions to be systematised and also to beexpanded in other areas, such as outside schools (i.e. recreational places) and atworkplaces.

Another issue of outmost importance is the promotion of scientifically sound andsystematic evaluation. Evaluation studies have already been initiated especially inthe prevention field, however improvement in internal and external evaluationactivities is considered necessary. Within this framework, training in evaluation issuesand development of research will contribute significantly to this issue.

The most important issue in demand reduction field appears to be the reinforcementof co-operation among professionals as well as between the latter and policy-makersand researchers. Comprehensive co-ordination of the different agencies, systematicexchange of opinions and expertise, and methodical connection between practice,research and policy will contribute to the enrichment of all types of intervention.Within this framework, the cooperation between specialised drug programmes andgeneral health services also need to be further strengthened.

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PPAARRTT IIVV

KKEEYY IISSSSUUEESS

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12. DRUG STRATEGIES IN EUROPEAN UNION MEMBER STATES

12.1 National Policies and strategies

Greek legislative policy on drugs since 1987 when Law 1729 was enacted hasbeen attempting a holistic approach to the problem by providing both legaland therapeutic confrontation. Having left behind the previous strictlyrepressive model, the introduction of the prevention model 13 years agocontributed to a more balanced approach with the emphasis put on repressionand on prevention and treatment at the same time. As it has been argued,Greek drug legislation as a whole follows on the one hand the“medical/prohibitive” pattern and on the other the pattern“permitted/prohibited” according to each specific case. The latter pattern isbeing followed by the Greek legislation on drugs since the amendment of Law1729/1987 in Law 2161/1993 that provided for the establishment ofExperimental Substitution Programmes with the administration of methadoneto addicted heroin users (Spinelli 1999).

One of the factors that differentiate Greece from other European countries -usually with higher prevalence rates of drug useis that Greece is among thecountries that follow the model of complete prohibition as regards drug use.Following a specific legal view, this is against both the Greek Constitution (1st

paragraph of the 7th article) and the Penal Code (Article 14), according towhich a punishment can be imposed on a citizen only in case of an actionperformed against someone else. In the case of drug use victim and victimizerare one and the same person (Chaidou 1995). Penalization of simple use inGreece seems to move beyond the United Nations Convention that wasratified in 1991 in Greece (Law 1990/1991) providing for the criminalization ofpossession, purchase and cultivation of drugs and psychoactive substancesfor personal use (Spinelli 1999).

However, since drug use is illegal in Greece a decisive key role in lawenforcement is assumed by the judicial system. Courts and judges have beenentrusted with the responsibility of discriminating between addicted and nonaddicted offenders charged for drug use and moreover between thosecharged for use and those charged for trafficking or dealing in the case ofcharges for possession of a certain amount of drugs. Both decisions arecrucial for the determination of the sentence. Law provides that thecharacterization of offenders as drug addicted users should derive from anexpert appraisement formed by a specialized detoxification center, anappropriate University sector or a medical jurisprudence service. Thisprovision, however, is not in force, a fact that eventually leads to the creationof associated problems. Spinelli (1999), refers to the difficulties faced indiscriminating between users and traffickers, since as it is indicated by astatistical overview of penalties imposed either on users or on traffickers,traces of inconsistencies in the determination of sentences are obvious. Thereare cases, where individuals convicted for drug use serve life imprisonment,although this is not the appropriate penalty according to the law, whereasthere are also individuals convicted for trafficking and dealing on which morelenient penalties than expected have been imposed. The latter, as she states,

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is mainly due to the fact that those offenders somehow achieved to becharacterized as users as well. For discriminating between users andtraffickers or dealers the exact drug amount possessed plays the decisiverole. The law states that the determination of the drug amount that could beconsidered as possessed or exchanged for personal use depends on therespective ministerial decrees. Such ministerial decrees have not been issuedyet and, thus, it is again up to the courts to decide on the severity of theoffence.

Another difficulty faced within the judicial system is that case hearingproceeds at a slow pace due to the large amount of case files that should betried. This, as has already been argued by the Public Prosecutor Association,does not provide a desired solution to the phenomenon of drugs where theprosecutors’ interventions constitute repressive measures.

Confrontation of the existing judicial problems are at the scope of the Ministerof Justice proposals (see also Chapter 1.1 Political framework in the drugfield) by the re-examination of some drug law offences, the reduction innumber of trial postponements and the establishment of new courts.Moreover, the All-Party Parliamentary Committee in March 2000, included inits proposals the need of unification of all existing drug laws aiming to theovercoming of legislative gaps and to a flexible adaptation to specific subjects.

In the domain of demand reduction the current situation reflects a multi-faceted approach to the problem. In the mid 90’s three major steps havebeen taken within the three levels of prevention that reinforced the attempt ofa holistic confrontation: the inauguration of the first prevention centers, thecreation of the methadone substitution programmes and the implementationof major initiatives aiming at the reintegration of former users. Moreover,although abstinence from drug use as well as physical and psychologicaldetoxification are the major aims of demand reduction activities, low thresholdservices have also been created to meet the need for harm reduction to userswho do not attend a treatment programme.

Reinforcement and expansion of the above activities are in the core of thenational strategy plan in the field of demand reduction. More specifically, inorder to ensure the development and the effectiveness of the existingprevention centres nationally and to continue the establishment of new ones,OKANA plans to reinforce the supervision over the local authorities, in orderto enhance productive collaboration between them. Further evaluationprogress as well as improvement of inter-connection among the centres arealso among the national strategy targets and were also proposed by the All-Party Parliamentary Committee. The Committee also argued for the morerapid development of health educational programmes within schools and theirexpansion to the first educational grades.

As regards therapy, included in the national plan are the expansion of all sortsof therapeutic programmes and the establishment of methadone maintenanceprogrammes as it was also proposed by the All-Party ParliamentaryCommittee. The Committee proposed also the continuation of substitution

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treatment with the administration of other substitutes besides methadone andthe decrease of substitution therapy duration. However, the Committeestressed that substitution programmes should not be viewed as a panaceaand that further development of drug-free therapeutic programmes was alsoimperative.

Repression measures are the second major part of national policy againstdrugs. Since law prohibits use, possession, trafficking and cultivation of drugs,repression forces that are constituted by the Police, the Port Police Corps, theFinancial and Economic Crimes Office and the Customs are involved in theprosecution of the above considered crimes. However, of major importance isconsidered drug trafficking, especially now that it develops within theframework of organized crime. Greece has been repeatedly characterized asa “cross-section for drug trafficking” between Asia, the Balkans and the rest ofWest Europe. Thus, emphasis has been put on the frontier guard through theestablishment of a specialized unit that comes under the police (see alsoChapter 1.1 Political framework in the drug field). The All-PartyParliamentary Committee, moreover, proposed for stricter legal measuresagainst drug-traffickers whereas as regards drug use there was disagreementamong the members in reference to the degree of liberalization.

Concluding, the following remark appears as important. Due to lack of a clear-cut policy framework that should combine the different philosophies of theauthorities involved at all the levels of confrontation (repression, prevention,judicial process) many difficulties are faced in practice when trying toapproach the phenomenon of drugs. Drawing on interviews given by socialworkers of the street work programmes, for example, one could infer thatcooperation between the police and those programmes is insufficient, sincepolice occasional repressive interference results in the removal and the splitof concentrated open drug scenes that constitute the target group of streetwork programmes. Moreover, sporadic arrests of such social workers on thestreets, as suspects for drug dealing, have also been observed embarrassingtheir work. Such difficulties could be overcome if a legal framework for streetwork programmes was laid down and in general if a unified drug policy wasfollowed. Although interministerial cooperation for unified drug policy planningand implementation is a legislative requirement, in practice cooperation andeffective communication are hindered due to organizational structuredifferences and bureaucracy. OKANA has been entrusted an important role inregard to improving interministerial cooperation, although, as the All-PartyParliamentary Committee argued, to succeed in this task its institutionalupgrade is considered as imperative (see also Chapter 12.2 Application ofnational strategies).

12.2 Application of national strategies

Policymaking and policy implementation are carried out at various levels ofsocial life. Deriving from the Parliament and executed by the government,legislative policy is applied with the mediation of three central agencies:OKANA, the Central Anti-Drug Coordinating Unit and the Judicial System.

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However, OKANA has also assumed the role of inter-ministerial co-operationand co-ordination.

OKANA was established in 1995 following Law 2161/1993 as a self-regulatinglegal entity under the Ministry of Health. Its aim is to plan and promote inter-ministerial co-ordination, to research into the drug problem as well as to makepolicy in regard to all levels of prevention.

According to the Law 2161/1993 primary prevention programmes should beapproved by the Ministry of Health. Proposals and organization of suchprogrammes can be carried out by OKANA as well as by the Church, the localauthorities, trade-union and governmental or private agencies provided that allthe appropriate proposals have been submitted to OKANA. As regards thislast stipulation excepted are only the programmes that have been developedby KETHEA, which do not need OKANA’s approval.

Many authorities are actively involved in the domain of primary prevention:Ministries (of Health and of Education and Religious Affairs), OKANA, localgovernments, educational and research institutes and non-governmentalorganizations. Primary prevention policy is actualized through theimplementation of respective programmes either by prevention centers or byother agencies to the overall population as well as through the implementationof health promotion programmes in schools.

Within the domain of secondary prevention the organizational infrastructure ofactivities’ implementation follows more or less a similar to the primaryprevention pattern. According to Law 1729/1987 the until then specializedtreatment units for drug addicts were placed among KETHEA’s programmes.Further to 1987 Law, the 1993 amendment (2161/1993) stipulated that theestablishment and functioning of all non-profiteering treatment centers fordrug addicts should be under the umbrella of the Ministry of Health, thatgrants the appropriate licenses following OKANA’s opinion. Entitled for theestablishment of secondary prevention units are the local governments,charity unions, the Church, universities and natural or legal persons withsimilar aims. Moreover, all treatment units that would be established fromthere on should be placed under the supervision and control of the Ministry ofHealth executed by OKANA. Excepted are only KETHEA’s programmes.

Involved in the implementation of secondary prevention programmes is alsothe Ministry of Justice. Most drug addicted prisoners served hitherto their termat the Korydallos and Patra prisons or at the Korydallos Prison PsychiatricHospital, where they received pharmaceutical treatment. Moreover, incollaboration with KETHEA, 18ANO and the “Narcotics Anonymous” theMinistry of Justice provided for voluntary programmes aiming at harmreduction and motivation to treatment. In 1999, Law 2721 was enacted thatprovided among others for the establishment of two detoxification units fordrug dependent prisoners, one in Thiva (Central Greece) and one inChalkidiki (North Greece). A Ministerial Decree has also been issued in 1999providing for the organization of the therapeutic programmes that would beimplemented within the established units (see also Chapter 1.2.1 Drug laws)

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Tertiary prevention is developed within most of the units that activate in thedomain of treatment. However, in reference to the reintegration of former drugusers to the job market the Ministry of Labour since 1996 has been attemptingthe creation of job opportunities by subsidizing employers or new free-lancersex-addicts. In particular, a Ministerial Decree issued in 1997 by the Minister ofLabour provided for the subsidize of employers for the employment of 290 ex-addicts, ex-prisoners and young delinquents. Moreover, in 1997 the Ministerof Labour issued a Decree providing for the subsidize of new free-lancersformer drug addicts or former prisoners aiming at the creation of 70 jobopenings (See also Chapter 1.2.1 Drug laws).

Repression policy is applied by four public bodies that are answerable to threedifferent Ministries: a) the Police (Ministry of Public Order), b) the Port PoliceCorps (Ministry of Merchant Marine), c) the Financial and Economic CrimesOffice and d) the Customs (both under the Ministry of Finance). Members ofthese four drug-law enforcement authorities constitute the Central Anti-DrugCo-ordinating Unit, with administrative and co-ordinating responsibilities. TheCentral Anti-Drug Co-ordinating Unit is a national information unit responsiblefor collecting data on drug-related deaths, seizures and arrests, and forsubmitting appropriate recommendations to the Ministerial Directorates incharge for policy making.

One of the major drug law offences that are prosecuted by the lawenforcement authorities and is attributed also to the geographical position ofGreece is trafficking. Specialized prosecution units contribute to theconfrontation of drug circulation within or through the country. Drug dealing ortrafficking within the country is prosecuted not only by general policemanpower but also by a police unit specializing in the fight against drugs.Moreover, the establishment of a frontier-police unit has reinforcedconfrontation of drug trafficking through the Greek frontiers, since among theirmain tasks is also the fight against drugs.

Co-operation among the law enforcement authorities takes place at the levelof information exchange so as to enhance positive results in the domain ofrepression. National repression authorities, moreover, collaborate withinternational ones such as INTERPOL or EUROPOL under the scope ofprosecuting the organized crime. However, co-operation between repressionand prevention authorities is also stated, since all repression authorities co-operate with OKANA and the Ministry of Health. Collaboration with preventionauthorities goes beyond the simple information exchange and refersfurthermore to the training of policemen in prevention in order to assumepreventive and informative roles as well.

Overall co-ordination among authorities responsible for drug issues -considered as necessary for the promotion of policy making- has beenundertaken by OKANA according to Law 2161/1993. Indicative of the attemptto a holistic coordinated approach is the synthesis of the steering committeeof OKANA. It consists of members from all Ministries competent in drugissues (Ministries of Health, of Public Order, of Justice, of Finance, of

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Education and Religious Affairs and of Merchant Marine), from the Centre ofTherapy for Dependent Individuals (KETHEA), from the Church and from localauthorities. However, the All-Party Parliamentary Committee in his final reportin March 2000 argued for OKANA’s institutional upgrade. The Committeeconsidered that as a prerequisite for OKANA to become an intermediaryorganization between the state and the NGOs and so that inter-ministrycoordination is actually secured. Change of OKANA’s legal basis should lendit prestige, administrative autonomy and flexibility.

Moreover, the Committee considered the governmental financing for demandand harm reduction activities as inadequate. What was proposed was asignificant rise of the State Budget funds in combination with theintensification of the attempt to secure funds from other governmental andnon-governmental sources as well.

12.3 Evaluation of national strategies

An overall evaluation of national strategies to combat drugs is quite difficult,since, although a number of activities has been developed at every level ofconfrontation (repression, prevention, judicial process), there exists no clear-cut policy framework that combines the different philosophies of the involvedauthorities.

However, OKANA (2000) has made it clear that promotion of evaluation isamong his main goals for the next three years. More specifically, thesystematic identification of information gaps aiming at a better drug-strategyplanning is considered of major importance. Under this scope research andsystematic use of research findings will also be promoted. OKANA has beenalready considering the above as a priority by supporting the National FocalPoint, by carrying out studies and research projects in the programmes underhis umbrella as well as by funding epidemiological research projects carriedout by other agencies. Moreover, to improve research and evaluation planningand coordination OKANA will enact a Department of Research andEvaluation.

Prospects and prerequisites for the reinforcement and the broadening of hisgoals have also been set by OKANA. The expansion of his subject to licitsubstances as well as further de-centralization and participation of more localcommunities stand as necessary prospects. However, political support,functional flexibility and enhance of state or private funds are considered asprerequisites for the efficient implementation of OKANA’s plan.

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13. COCAINE AND BASE/CRACK COCAINE

Indications that cocaine use has increased in the last years is coming fromvarious sources of information.

13.1 Different patterns and users groups

13.1.1 Epidemiological data

In the epidemiological studies in the general and the high-school studentspopulation in 1998 revealed the increase in cocaine/crack use. Thepercentage of high-school students who reported cocaine/crack use in 1998was 2%. In the general population 2.5% among those aged 18-35 years in1998 had used cocaine/crack.

Multiple logistic regression analysis was employed to examine the risk factorsof cocaine/crack use, using cannabis users as reference group in the high-school student population.

According to the results the most significant risk factor for cocaine/crack userelatively to cannabis was use of tranquilizers or sedatives by their siblings(OR= 18.9, p<0.001)

Other significant risk factors were:

• close friends using tranquilizers or ecstasy (OR= 3.8, p<0.05 and 4.6p<0.01, respectively)

• father’s death (OR = 4.3 p<0.001)

• suicide attempts (OR = 3, p<0.001), and

• exhibiting antisocial behaviour (OR = 2.7, p<0.01)

Less important factors were police arrests, running away from home andbeing a boy.

13.1.2 Data from dependent individuals

According to data from the Treatment Demand indicator, cocaine use hasincreased in the last 5 years; in 1999 cocaine use was reported by 14.8% ofdrug users who requested treatment, compared to 10% in 1996.

Cocaine users seem to prefer out-patient treatment services; 2.4% of clientsrequesting treatment from the out-patient services reported cocaine as theirmain substance of abuse, while the equivalent percentage in the in-patientunits was 1%.

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Of the cocaine users clients in 1999, the vast majority reported smoking(95.9%) and by mouth (49.7%) as routes of administration. A largepercentage had a stable job (42.5%), while 6.2% were university graduates.

According to data derived from the research conducted in recreational placesin Athens in 1998, among club/party goers cocaine is the most popularstimulant (10.1%). Its use in the different music scenes in Greece variesgreatly; the higher percentage is shown among young people who prefer theTrance music scene (26.1%), followed by those who frequent the House andthe Rock scene (10.7% and 10.4%, respectively). A small minority of theyoung people who prefer the Greek Popular scene reported cocaine use(2.7%).

13.2 Problems and needs for services

Studies investigating health or social problems of cocaine users as a separategroup have not been conducted in Greece as yet, probably because theincrease in its use has been identified only recently.

13.3 Market

13.3.1 Purity and Price

The National Chemical Laboratory analyses samples of seized quantities ofdrugs. According to them, cocaine is a white or almost-white fine powder witha characteristic odour; sometimes it contains hard colourless crystals (“rockcocaine”).

Cocaine adulterants do not change its physical appearance as they are alsowhite. The adulterants most frequently found in cocaine are:

• By-products: Ecgonine, Benzoylecgonine, Methylecgonine, Cinnamoyl-cocaine.

• Pharmacologically active substances: non-controlled local anaestheticsubstances (Procaine, Lidocaine), other active substances (Caffeine,Paracetamol).

• Diluents: Lactose, Mannitol, Glucose, Soda.

Cocaine purity in the samples analysed ranges from 50 to 60%.

The retail price of cocaine ranges between 58.30 and 87.40 Euros per doseand the trafficking price ranges from 29,130 to 58,260 Euros per kg.

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13.3.2 Trafficking, dealing and distribution patterns

The Police describes the recent distribution patterns of cocaine in thedomestic illegal market as “dynamic”, since this market has been broadenedby new user groups, coming from various socioeconomic backgrounds.

Cocaine trafficking is limited among friends or acquaintances; is it not foundas yet in the open street market.

S u p p l y r o u t e s

Data from seizures indicate that 67% of cocaine is transferred by sea, 25.5%by road and 7.7% by plane. A new popular route for small amounts is viacourier services.

Cocaine is imported in Greece mainly from Latin America, Bulgaria, Albaniaand the Netherlands.

13.4 Intervention projects

Intervention projects especially designed to cocaine users do not exist.According to health professionals working in the treatment sector, users whoapproach the therapeutic programmes having cocaine as their mainsubstance of abuse are very few. The need for the implementation ofspecilised programmes has not arisen yet.

14. INFECTIOUS DISEASES

14.1 Prevalence of HCV, HBV and HIV among drug users

14.1.1 Hepatitis

As mentioned in Chapter 3.3, the Greek Focal Point receives data on hepatitisfrom various sources in aggregated form.

As the prevalence for hepatitis B among drug users is quite low, thediscussion will be mainly focused on hepatitis C, which consists the biggestproblem related to infectious diseases in Greek drug users.

Data are classified according to their nature (test-results or self-reports) andaccording to the type of source.

• Test results in 1999

P u b l i c L a b o r a t o r i e s i n A t h e n s

The Laboratory of Syngros General Hospital and the Laboratory of theNational School of Public Health are the two major Reference Centres forhepatitis B and C testing. Most therapeutic centres in Athens sent their clients

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for medical tests in these centres. Users tested there are mostly injectors, butfor the moment they are not separated from the overall number of users.

In the Syngros Laboratory, out of the 327 drug users tested for hepatitis B14 (4.3%) were found infected, and out of the 317 tested for hepatitis C, 178(56.1%) were found infected (Figure 31).

In the laboratory of the National School of Public Health (NSPH), out of the393 users tested, 8 (2%) were infected with hepatitis B and 162 (41.2%) withhepatitis C (Figure 31).

T h e r a p e u t i c p r o g r a m m e s

Test results from the methadone substitution programme, implemented byOKANA, derive from two out of its four units, which function in Thesaloniki.Out of the 174 intravenous drug users tested, 11 (6.3%) were found infectedwith the hepatitis B virus and 142 (81.6%) with the hepatitis C virus (Figure31).

Data from one of the two major drug-free therapeutic agencies, the Centre ofTherapy for Dependent Individuals (KETHEA) indicate that out of 286 IVDUstested, 10 (3.5%) and 148 (51.7%) had hepatitis B and C respectively (Figure31).

The Psychiatric Hospital of Attica (Athens Prefecture) has a special unit fordependent individuals, 18 ANO, which has implemented a special programmefor women. Of the 72 women treated since the programme started, i.e. in thelast 3 years, 4 (5.5%) had hepatitis B and 31 (43%) hepatitis C (Figure 31).

In the Greek prisons, testing for infectious diseases is voluntary butencouraged. Of the 130 IVDUs tested in 1999, 68 (52.3%) were infected withhepatitis B and 82 (63.1%) by hepatitis C.

Test results data are summarised in Figure 31.

SOURCES: Andreas Syngros Hospital, NSPH, OKANA, KETHEA, 18 ANO, Ministry of Justice, 2000.

Figure 31: Test results for Hepatitis C as reported by the variousrelevant sources in 1999

56,3

41,2

81,6

51,7

43

63,1

0

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50

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70

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90

SyngrosHospital

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KETHEA 18 ANOPrograme forwomen users

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%

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The highest percentage of users infected with hepatitis C is found in thesubstitution programme. Clients there are, heavy users, have a long drugcareer and several drug-related health problems, because they are selectedon the basis of such criteria.

The vast majority of the users infected in the above sources were men, asthe majority of their clients are also men. In most cases infected users belongto the 25-35 age group; as expected, in the substitution programme, most ofthem are older, over 35.

• Self-reports in 1999

Data from the Treatment Demand Indicator show that out of the 1,096 usersinterviewed in 1999 696 (65.6%) reported having had a test for infectiousdiseases, 32 out of which did not know the test result. Of the rest, 70 (10.5%)reported hepatitis B infection and 285 (42.9%) reported hepatitis C.

Self-reports from KETHEA deriving from the 1,474 users interviewed in 1999with the TDI protocol, show that 22% were infected with hepatitis C.

Data from KETHEA’s adolescent and young adults unit “STROFI” for 1999,show that the majority of adolescents had never had a test for any otherinfectious diseases. Of those who had, 4.7% were infected with hepatitis Cand 1.1% with hepatitis B. The low percentages can be attributed to the youngage of the population and the fact that intravenous use among them is rare -they are mostly cannabis users.

The Psychiatric Hospital of the Korydallos Athens prison uses the TDIprotocol, as said in previous sections. Self-reported data from this sourceindicated that of the 35 inmates tested, 8.6% were found infected withhepatitis B and 25.7% with hepatitis C.

Self-reported data from the above sources are summarised in Figure 32.

SOURCES: Greek REITOX Focal Point, KETHEA, Korydallos Prison, 2000

Figure 32: Self-reports for Hepatitis C in 1999

42,9

22

25,7

0

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15

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30

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40

45

50

TDI KETHEA Prison inmates

%

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Self-reported hepatitis prevalence rates are quite lower than those comingfrom actual tests performed. It seems that users are either not altogethertruthful about their health status, at least concerning infectious diseases, ornot aware of their situation, or probably both. Whatever the case, theunderreporting prevalent in self-reported data indicates that their reliability islow.

14.1.2 HIV/AIDS

AIDS prevalence in Greece among IVDUs remains low compared to otherEuropean countries, although a trend towards stabilisation appears in Europetoo in the last years.

According to data from the Centre for the Control of AIDS and STDs (KEEL)in 1999 the overall number of new AIDS cases was 98, out of which 4 wereintravenous drug users, most them belonging to the 15-39 age group (Figure33).

Figure 33: AIDS cases among drug users (1985-1999)

SOURCE: Centre for the Control of AIDS and STDs, 2000.

The low prevalence of AIDS appears contradictory to the high prevalence ofneedle sharing and other risk behaviours among IVDUs, as discussed inprevious sections. Qualitative data that the Focal Point has collected indicatethat health professionals are trying to interpret the phenomenon. Several ofthem foresee a sharp increase in the years to come, as in Greece issuesrelated to drugs appear usually later that in other European countries.Nevertheless, one of the possible interpretations that key-experts offer is thatGreek IVDUs share needles only with relatives or close friends they know welland this minimises the risk of getting infected. Another interpretation is thatGreek IVDUs, belonging to a marginalised and socially excluded social group,

0

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1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

N

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do not travel abroad and their contacts with IVDUs from other Europeancountries, where the virus is more prevalent, is limited.

14.1.3 Data on infectious diseases from special studies

The interest shown in the investigation of HIV/AIDS prevalence among drugusers in the beginning of the 90’s has, in the last years subsided, probablybecause the prevalence of this infectious disease is low in Greece.

In the last few years two studies have examined the risk behaviour and theprevalence of infectious diseases among prison inmates in Greece. Thesestudies have already been mentioned in this report when risk behaviours werediscussed (see Chapters 2.2 Drug use in the population and 2.3 Problemdrug use). Here, their findings relevant to the prevalence of infectiousdiseases, will be presented.

The OKANA study in prisons, conducted in two Greek prisons, examined theprevalence of HIV and hepatitis among injecting and non-injecting drug users(Table 20).

Table 20: Prevalence of HIV and hepatitis in Greek prisoners

IVDus Non-IVDUs

(365)%

(168)%

Anti-HIV -1 0.31 0

Anti-HCV 80.6 9.5

Anti-HBc 67.2 46.4

HBsAg 7.2 4.8

Anti-HDV 3.3 0

1 One user

SOURCE: Malliori et al. 1998

The difference between injecting and non-injecting drug users is great in allcategories; injecting drug users seem to be at higher risk for all infectiousdiseases than those users who do not inject. This is particularly true forhepatitis C, where the majority of injecting users (80.6%) are infected with.Only one injecting user was found infected with HIV. The most important riskfactors for HCV infection were injecting while in prison and multipleimprisonments (Malliori et al. 1998).

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As discussed in Chapter 2.3.2 Risk behaviours in a study conducted by theNational School of Public Health, needle sharing among injectors decreasedbetween 1993 and 1998, while use of condoms increased. As a result, thepercentage of seropositive users decreased from 2.5% in 1993 to 0.8% in1998. On the contrary, the prevalence of infectious diseases increased;whereas in 1993 no user was found positive for hepatitis B or C, in 1998,4.9% of the users were found positive for hepatitis B surface antigen (HbsAgand 49.4% positive for hepatitis C) (Kornarou et al. 1999).

14.2 Determinants and consequences

The risk behaviours exhibited by drug users have been discussed in detail inChapter 2.3. It was emphasised that a high percentage of intravenous drugusers share needles with each other and that this behaviour takes the form ofa ritual in Greece with which users prove their trust and friendship.

A large number of IVDUs have not been tested for infectious diseases. Thenumber would probably be higher if the therapeutic centres did not considermedical tests as a prerequisite for admission. Even among users who take thetest, a large percentage do not ask for the result. This “voluntary ignorance”might be an inhibitory factor to prevention, as, it has been found that, at leastfor HIV, knowledge of one’s own positive serostatus resulted in them takingincreased precautions (using condoms, avoiding lending needles to others) toprotect their friends from catching the disease (Schlumberger et al. 1999).

Although HIV remains at low levels hepatitis prevalence is high. Programmeson safe use have been implemented in Greece in the last few years. It isperhaps very early to expect quantifiable results.

14.3 New developments and uptake of prevention, harm reduction and care

Due to the alarming spread of STDs among the drug users population,various agencies have become actively involved in preventing infectiousdiseases and in promoting harm reduction from drugs. Their interventionsrange from education on safe drug use and safe sex to syringe exchange,testing and treatment (Table 1).

Therapeutic programmes and low threshold services systematically organizeseminars on safe drug use, prevention of infectious diseases and hygieneissues. For example, the KETHEA Multiple Intervention Centre, incollaboration with the Centre for the Control of AIDS and STDs (KEEL) andthe “Médecines sans Frontières” association, implements on a fortnight basisspecialized seminars to drug users who approach the Centre. These seminarsdeal with the following issues: a. interactive effects of drugs and associatedrisks, b. information on harm reduction, c. prevention from AIDS and HepatitisB and C, and d. first aid information. Regular educational seminars on safe

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drug use and prevention of infectious diseases are also organized by theSocial Service of OKANA Help Centre.

Moreover, treatment and low threshold services provide their clients with theopportunity to have infectious diseases or other health-related tests, incooperation with general hospitals and local health services. In this context,the Therapeutic Community “EXODOS” of KETHEA has organized since 1998case-history records for all clients and it has also implemented in collaborationwith the General Hospital of Larissa a vaccination programme for Hepatitis Bavailable to all persons in treatment. The OKANA Help Centre also offerstesting possibilities through its general health clinic and the fully equippedMicrobiological Laboratory established in 1999. Clients of the substitutionprogrammes in Athens as well as drug users approached by the OKANAstreetwork programme are referred to the medical services of the OKANAHelp Centre.

The role of the streetwork programmes in preventing infectious diseases is ofoutmost importance. Apart from referrals to general hospitals for infectiousdiseases and other medical tests, they also provide on site information andcounselling on harm reduction, on safe drug use and on safe sex. In addition,the OKANA streetwork programme distributes clean equipment for drug use(i.e. syringes and serum), while it motivates drug users to exchange their usedsyringes with clean ones. Syringe exchange takes place within the premisesof the OKANA Help Centre. In order to promote safe sex, both streetworkprogrammes in Athens distribute condoms to drug users.

Treatment and psychological support to infected individuals are provided bythe hospital “Andreas Syngros” in Athens as well as by general hospitals atregional level.

Table 21. Programmes and interventions for combating infectious diseases

Programmes / Agencies Type of Interventions

Prevention centres

• Health promotion programmes to students

• Information and sensitisation seminars tostudents, to health professionals and to thegeneral public

Specialized Therapeutic Programmes• Seminars on prevention of infectious diseases

• Referrals to general hospitals for testing andvaccination

Low Threshold Programmes

• Seminars on safe drug use, safe sex andprevention of infectious diseases

• Counselling and social services

• Exchange of syringes

• Referrals to general hospitals for testing,vaccination and treatment

(continued to next page Ê )

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Streetwork Programmes

• Information and counselling on safe drug use,safe sex, prevention of infectious diseases

• Distribution of information leaflets, condomsand syringes

• Referrals to the medical services of theOKANA Help Centre and to General Hospitalsfor testing and vaccination

Programmes in PrisonsSeminars on health issues and on prevention ofinfectious diseases to prisoners and personnel

Centre for the Control of AIDS and STDs(KEEL)

• Monitoring prevalence of HIV

• Distribution of informative leaflets

• Specialized telephone help line

• Counselling, psychological, psychiatric andsocial services

• Seminars addressed to doctors, nurses,mental health professionals, students, policeofficers, local agencies

• Cooperation with specialized therapeuticprogrammes for seminars on safe drug useand sex

• Research studies on infectious diseases

Hellenic School of Public Health (referencecentre for infectious diseases)

• Testing and vaccination

• Treatment

Laboratory of the “Andreas Syngros”Hospital (reference centre for infectiousdiseases)

• Testing and vaccination

• Psychosocial services

• Treatment

Associations of volunteers (i.e. “Médecinssans Frontières”)

Cooperation with specialized harm reductionprogrammes for seminars to drug users andpersonnel regarding health issues and preventionof infectious diseases

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The Centre for the Control of AIDS and STDs (KEEL), which was establishedin 1992, has developed an well-organized network of prevention, treatmentand social services. This is addressed to general population, and to infectedpersons and their families. Moreover, KEEL is considerable active inimplementing training and research programmes regarding infectiousdiseases as well as in sensitizing the lay public through TV and radiobroadcasts. Training of professionals in issues of infectious diseases is alsoprovided in cooperation with European and international organizations. Forexample, in 1999 the KETHEA organized in collaboration with the Ministry ofHealth and the University of California (San Diego) a congress entitled “Use ofpsychoactive substances and HIV/AIDS: new research fields”.

Evaluation regarding prevention and care of infectious diseases has not beendeveloped yet. Lack of specific indicators that would be included in theevaluation studies of the drug-specific treatment programmes and broaderproblems in the evaluation of streetwork programmes appear to be the mainreasons for that. Nevertheless, according to more general health and harmreduction indicators, evaluation results seem to be positive. Substitutionprogrammes refer a stable increase of the physical health improvement oftheir clients up to 80-90%, while the number of the syringes exchanged by theOKANA Help Centre in 1999 was considerably increased compared to thosein 1998 (86,819 and 46,660 syringes, respectively). Moreover, while in 19981,297 drug users visited the medical services of the Help Centre, this numberwas increased in 1999 (1,747 drug users, from whom 621 were new clients).

However, several difficulties have been reported regarding prevention andcare of infectious diseases. Although therapeutic and harm reductionprogrammes constantly refer drug users to general hospitals for medical andinfectious diseases tests, they appear to be unwilling to have these tests orinquire about the results in many cases. Drug users seem to prefer medicalservices specifically addressed to them (i.e. OKANA Help Centre) to generalhospitals. Moreover, they seem to be afraid of being stigmatized by thehospitals’ personnel. The latter is more common at the local and the regionallevel, where sensitization programmes are lacking. Another difficulty is thefact that some of the prevention and the therapeutic programmes (especiallythose of the public sector) do not organize education seminars regardingprevention of infectious diseases on a regular basis. Thus, on the grounds ofthese difficulties it seems to be necessary for prevention programmes ofinfectious diseases not only to be intensified by all therapeutic and preventionagencies, but also to be expanded at the local and the regional level.

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AANNNNEEXX

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Table I. Prevention Centers established by OKANA (1997-2000)(Total Number: 51 Prevention Centres)

GeographicalRegion

TITLE Town/City InaugurationYear

THRACE 1) Information & Prevention Center Against Drugs Xanthi 1997

2) Information & Prevention Center Against Drugs«ELPIDA»

Alexandroupoli 1998

3) Prevention Center Against Substance Use «ORPHEAS» Komotini 1999

MACEDONIA 1) Communication & Prevention Center AgainstPsychoactive Substances «KEP PIERIAS»

Katerini 1997

2) Center for Preventing and Combating Drugs Kavala 1998

3) Drug Dependence Prevention & Health Promotion Center«PYXIDA»

Thessaloniki 1998

4) Prevention Center for Combating Substances «ELPIDA» Thessaloniki 1998

5) Prevention Center Against Drugs Florina 1998

6) Prevention Center Against Substances «ORIZONTES» Kozani 1998

7) Information & Prevention Center Against Drugs«DIEXODOS»

Kastoria 1999

8) Prevention Center Against Substance Use «PNOI» Chalkidiki 1999

9-10) Prevention Centers «SIRIOS» (2 Centers) Thessaloniki 2000

11 Prevention Center Against Substances «ORIZONTES» Grevena 2000

HEPIRUS 1) Counselling Center for Combating Drugs Ioannina 1996

2) Prevention Center Arta 1997

3) Prevention Center Against Substance Use «ARIADNE» Igoumenitsa 1999

4) Prevention Center Against Drugs and Other Substances«KE.PRO.NA.P.»

Preveza 2000

THESSALIA/ 1) Social Intervention Center Trikala 1997

SPORADES 2) Prevention Center Against Dependence Karditsa 1997

3) Drug Prevention Center «PROTASI ZOIS» Volos 1998

4) Prevention Center Against Substances «ORPHEAS» Larisa 1999

CENTRAL 1) Drug Prevention Center Chalkida 1997

THESSALIA 2) «Protasi Zois - Drug Use Prevention» LIvadia 1998

3) Municipal Prevention Unit «ODYSSEUS» Agrinio 1998

4) Prevention & Information Center Against Drugs Lamia 1998

PELOPONNESE 1) Prevention Center Against Substance Use«INTERVENTIONS»

Amaliada 1998

2) Drug Prevention Center Patra 1998

3) Information - Prevention & Sensitization Center AgainstPsychoactive Substances «KEPEPSO»

Kalamata 1999

4) Prevention Center Against Substance Use «DIOLKOS» Korinthos 2000

ATTICA 1-3) Counselling Center Against Drugs «ODYSSEUS»

(3 Centers)

Piraeus / Keratsini /Nikaia

1997

4-7) Drug Prevention & Health Promotion Center «ATHENAHEALTH» (4 Centers)

Athens 1998

8) Prevention & Information Center Peristeri 1998

9) Social Intervention Center –– Joint Municipal Enterpriseof Alimos, Argiroupoli, Elliniko & Glyfada

Athens 1998

10) Center for the Prevention of Substance Use & thePromotion of Health

Zografou 2000

(continued to next page Ê)

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GeographicalRegion

T I T L E Town/City InaugurationYear

IONIANISLANDS

1) Municipal Drug & AIDS Prevention Unit «NIKOSMOROS»

Corfu 1997

2) Drug Prevention Center Against Substances «STORGI» Zakinthos 1998

NORTHEAST 1) Prevention Center Against Substance Use Hios 1998

AEGEAN 2) Prevention Center Against Substance Use «PNOI» Lesvos 2000

3) Drug Prevention and Health Promotion Center Samos 2000

CYCLADES 1) Prevention Center Against Substances Paros 1998

2) Prevention Center Against Substances Siros 1998

DODECANESE 1) Drug Prevention Center «IPPOKRATIS» Kos 1999

2) Center for the Prevention of Substance Use and forHealth Promotion «DIMIURGIA»

Rhodes 2000

CRETE 1) Prevention Center Against Drugs Rethimnon 1997

2) Prevention Center Against Substances Hania 1998

158

Table II. Treatment units, geographical location & coverage(Total number: 28 Treatment Units)

UNITS PARENT INSTITUTION GEOGRAPHICAL LOCATION& COVERAGE

Residential Treatment

«PAREMVASI» Alternative Therapeutic Community KETHEA Rafina (Prefecture of Attica)

«NOSTOS» Therapeutic Community KETHEA Piraeus (Aegean Islands, Crete &Southern Greece in general)

«ITHACI» Therapeutic Community KETHEA Sindos, Thessaloniki (NorthernGreece)

«EXODOS» Therapeutic Community KETHEA Larissa (Central Greece)

Residential Therapeutic Programme - Drug &Alcohol Dependence Unit «18 ��»

Attica State PsychiatricHospital

Haidari (Prefecture of Attica)

Drug Dependence Treatment Unit Thessaloniki StatePsychiatric Hospital

Thessaloniki (Northern Greece)

«PHILIMON» Residential Therapy Centre for Drug-Dependent Persons

«PHILIMON» Pefki (Prefecture of Attica)

Programme for Dependent Women – Drug &Alcohol Dependence Unit «18 ��»


Filothei (Prefecture of Attica)

Non-Residential Treatment

A d u l t s

«DIAVASSI» Open Therapeutic Community KETHEA Athens

«DIAVASSI» Evening Therapeutic Programme KETHEA Athens

«IASON» Mental Health Centre Athens

Programme for Individuals with Dual Diagnosis –Drug Dependence Unit «18 ��»


Athens

Therapeutic Programme «��» Dept. of Psychiatry,Medical School, University

of Athens / OKANA

Athens

Drug-Free Therapeutic Programme «GEFIRA » OKANA Patras (Peloponnese)

Programme of Family Therapy & CounsellingDrug & Alcohol Dependence Unit «18 ��»


Athens

Alternative Therapeutic Programme «ARGO» Thessaloniki StatePsychiatric Hospital

Thessaloniki (Northern Greece)

Open Therapeutic Programme «ARIADNE» KETHEA Heraklion (Crete)

A d o l e s c e n t s

«STROPHI» Open Therapeutic Community KETHEA Athens

Secondary Prevention Centre KETHEA Athens

Department for Adolescents and Young AdultsDrug & Alcohol Dependence Unit «18 ��»


Athens

Counselling Centre in the Public ProsecutorsOffice in Athens for Young Drug Users Offenders

KETHEA Athens

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UNITS PARENT INSTITUTION GEOGRAPHICAL LOCATION& COVERAGE

Substitution Programmes

Methadone Substitution Programme, 1st Unit OKANA Athens

Methadone Substitution Programme, 2nd Unit OKANA Athens

Methadone Substitution Programme, 1st Unit OKANA Thessaloniki

Methadone Substitution Programme, 2nd Unit OKANA Thessaloniki

Methadone Maintenance Programme OKANA Athens

Low Threshold Programmes

Multiple Intervention Centre KETHEA Athens

Help Centre OKANA Athens

GREECE DRUG SITUATION 2000 - emcdda

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