DRUG WORLD 8 - GLOBAL OVERVIEW OF DRUG DEMAND AND SUPPLY - United Nations Office on Drugs and Crime
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GLOBAL OVERVIEW OF
DRUG DEMAND AND SUPPLY
Latest trends, cross-cutting issues
2
WORLD
2018
DRUG
REPORT© United Nations, June 2018. All rights reserved worldwide. ISBN: 978-92-1-148304-8 eISBN: 978-92-1-045058-4 United Nations publication, Sales No. E.18.XI.9 This publication may be reproduced in whole or in part and in any form for educational or non-profit purposes without special permission from the copyright holder, provided acknowledgement of the source is made. The United Nations Office on Drugs and Crime (UNODC) would appreciate receiving a copy of any publication that uses this publication as a source. Suggested citation: World Drug Report 2018 (United Nations publication, Sales No. E.18.XI.9). No use of this publication may be made for resale or any other commercial purpose whatsoever without prior permission in writing from UNODC. Applications for such permission, with a statement of purpose and intent of the reproduction, should be addressed to the Research and Trend Analysis Branch of UNODC. DISCLAIMER The content of this publication does not necessarily reflect the views or policies of UNODC or contributory organizations, nor does it imply any endorsement. Comments on the report are welcome and can be sent to: Division for Policy Analysis and Public Affairs United Nations Office on Drugs and Crime PO Box 500 1400 Vienna Austria Tel: (+43) 1 26060 0 Fax: (+43) 1 26060 5827 E-mail: wdr@un.org Website: https://www.unodc.org/wdr2018
PREFACE
Both the range of drugs and drug markets are Drug treatment and health services continue to fall
expanding and diversifying as never before. The short: the number of people suffering from drug use
findings of this year’s World Drug Report make clear disorders who are receiving treatment has remained
that the international community needs to step up low, just one in six. Some 450,000 people died in
its responses to cope with these challenges. 2015 as a result of drug use. Of those deaths,
167,750 were a direct result of drug use disorders,
We are facing a potential supply-driven expansion
in most cases involving opioids.
of drug markets, with production of opium and
manufacture of cocaine at the highest levels ever These threats to health and well-being, as well as to
recorded. Markets for cocaine and methampheta- security, safety and sustainable development,
mine are extending beyond their usual regions and, demand an urgent response.
while drug trafficking online using the darknet con-
The outcome document of the special session of the
tinues to represent only a fraction of drug trafficking
General Assembly on the world drug problem held
as a whole, it continues to grow rapidly, despite
in 2016 contains more than 100 recommendations
successes in shutting down popular trading
on promoting evidence-based prevention, care and
platforms.
other measures to address both supply and demand.
Non-medical use of prescription drugs has reached
We need to do more to advance this consensus,
epidemic proportions in parts of the world. The
increasing support to countries that need it most
opioid crisis in North America is rightly getting
and improving international cooperation and law
attention, and the international community has
enforcement capacities to dismantle organized crimi-
taken action. In March 2018, the Commission on
nal groups and stop drug trafficking.
Narcotic Drugs scheduled six analogues of fentanyl,
including carfentanil, which are contributing to the The United Nations Office on Drugs and Crime
deadly toll. This builds on the decision by the (UNODC) continues to work closely with its
Commission at its sixtieth session, in 2017, to place United Nations partners to assist countries in imple-
two precursor chemicals used in the manufacture menting the recommendations contained in the
of fentanyl and an analogue under international outcome document of the special session, in line
control. with the international drug control conventions,
human rights instruments and the 2030 Agenda for
However, as this World Drug Report shows, the prob-
Sustainable Development.
lems go far beyond the headlines. We need to raise
the alarm about addiction to tramadol, rates of In close cooperation with the World Health Organi-
which are soaring in parts of Africa. Non-medical zation, we are supporting the implementation of
use of this opioid painkiller, which is not under the International Standards on Drug Use Prevention
international control, is also expanding in Asia. The and the international standards for the treatment of
impact on vulnerable populations is cause for seri- drug use disorders, as well as the guidelines on treat-
ous concern, putting pressure on already strained ment and care for people with drug use disorders in
health-care systems. contact with the criminal justice system.
At the same time, more new psychoactive substances The World Drug Report 2018 highlights the impor-
are being synthesized and more are available than tance of gender- and age-sensitive drug policies,
ever, with increasing reports of associated harm and exploring the particular needs and challenges of
fatalities. women and young people. Moreover, it looks into
1WORLD DRUG REPORT 2018
increased drug use among older people, a develop- Next year, the Commission on Narcotic Drugs will
ment requiring specific treatment and care. host a high-level ministerial segment on the 2019
target date of the 2009 Political Declaration and
UNODC is also working on the ground to promote
Plan of Action on International Cooperation
balanced, comprehensive approaches. The Office
towards an Integrated and Balanced Strategy to
has further enhanced its integrated support to
Counter the World Drug Problem. Preparations are
Afghanistan and neighbouring regions to tackle
under way. I urge the international community to
record levels of opiate production and related secu-
take this opportunity to reinforce cooperation and
rity risks. We are supporting the Government of
agree upon effective solutions.
Colombia and the peace process with the Revolu-
tionary Armed Forces of Colombia (FARC) through
alternative development to provide licit livelihoods
free from coca cultivation.
Furthermore, our Office continues to support efforts
to improve the availability of controlled substances
for medical and scientific purposes, while prevent-
ing misuse and diversion – a critical challenge if we Yury Fedotov
want to help countries in Africa and other regions Executive Director
come to grips with the tramadol crisis. United Nations Office on Drugs and Crime
2CONTENTS
BOOKLET 1 EXECUTIVE SUMMARY — CONCLUSIONS AND POLICY IMPLICATIONS
GLOBAL OVERVIEW OF DRUG DEMAND AND SUPPLY
BOOKLET 2 Latest trends, cross-cutting issues
PREFACE. . ..................................................................................................... 1
EXPLANATORY NOTES................................................................................. 5
KEY FINDINGS.............................................................................................. 6
INTRODUCTION.. .......................................................................................... 9
A. EXTENT OF DRUG USE�������������������������������������������������������������������������� 11
More than a quarter of a billion people use drugs globally������������������������������������������������������������ 11
Trends in drug treatment are consistent with changing patterns
of drug use in different regions������������������������������������������������������������������������������������������������������ 13
B. HEALTH CONSEQUENCES OF DRUG USE����������������������������������������������� 14
Almost 11 million people worldwide injected drugs in 2016��������������������������������������������������������� 15
One in eight people who inject drugs is living with HIV�������������������������������������������������������������� 16
Injecting drugs is a major route for transmission of the HCV virus���������������������������������������������� 17
Coverage of core interventions to prevent spread of HIV and HCV among
PWID remains poor and insufficient��������������������������������������������������������������������������������������������� 19
Deaths attributable to drug use remain high globally�������������������������������������������������������������������� 21
C. EXTENT OF DRUG SUPPLY��������������������������������������������������������������������� 28
Drug cultivation and production��������������������������������������������������������������������������������������������������� 28
Drug seizures��������������������������������������������������������������������������������������������������������������������������������� 29
Drug trafficking via the darknet is a growing challenge for authorities������������������������������������������ 33
GLOSSARY.. .................................................................................................59
REGIONAL GROUPINGS. . .............................................................................60
ANALYSIS OF DRUG MARKETS
BOOKLET 3 Opioids, cocaine, cannabis, synthetic drugs
DRUGS AND AGE
BOOKLET 4 Drugs and associated issues among young people and older people
WOMEN AND DRUGS
BOOKLET 5 Drug use, drug supply and their consequences
3WORLD DRUG REPORT 2018
Acknowledgements
The World Drug Report 2018 was prepared by the Research and Trend Analysis Branch, Division for
Policy Analysis and Public Affairs, United Nations Office on Drugs and Crime, under the supervision
of Jean-Luc Lemahieu, Director of the Division, and Angela Me, Chief of the Research and Trend
Analysis Branch.
General coordination and content overview Editing
Chloé Carpentier Jonathan Gibbons
Angela Me
Graphic design and production
Analysis and drafting Anja Korenblik
Philip Davis Suzanne Kunnen
Kamran Niaz Kristina Kuttnig
Thomas Pietschmann
Coordination
Data management and estimates production Francesca Massanello
Enrico Bisogno
Data support
Coen Bussink
Diana Camerini
Jesus Maria Garcia Calleja (WHO)
Chung Kai Chan
Hernan Epstein
Sarika Dewan
Riku Lehtovuori
Smriti Ganapathi
Andrea Oterová
Umidjon Rakhmonberdiev Administrative support
Ali Saadeddin Anja Held
Keith Sabin (UNAIDS) Iulia Lazar
Antoine Vella
Review and comments
The World Drug Report 2018 benefited from the expertise of and invaluable contributions from
UNODC colleagues in all divisions.
The Research and Trend Analysis Branch acknowledges the invaluable contributions and advice
provided by the World Drug Report Scientific Advisory Committee:
Jonathan Caulkins Charles Parry In memoriam
Paul Griffiths Peter Reuter Brice de Ruyver
Marya Hynes Francisco Thoumi
Vicknasingam B. Kasinather Alison Ritter
Letizia Paoli
The research and production of the joint UNODC/UNAIDS/WHO/World Bank estimates of
the number of people who inject drugs were partly funded by the HIV/AIDS Section of the Drug
Prevention and Health Branch of the Division for Operations of UNODC.
4EXPLANATORY NOTES
The boundaries and names shown and the designa- The data on population used in the World Drug
tions used on maps do not imply official endorsement Report are taken from: World Population Prospects:
or acceptance by the United Nations. A dotted line The 2017 Revision (United Nations, Department of
represents approximately the line of control in Economic and Social Affairs, Population Division).
Jammu and Kashmir agreed upon by India and Paki-
References to dollars ($) are to United States dollars,
stan. The final status of Jammu and Kashmir has
unless otherwise stated.
not yet been agreed upon by the parties. Disputed
boundaries (China/India) are represented by cross- References to tons are to metric tons, unless other-
hatch owing to the difficulty of showing sufficient wise stated.
detail. The following abbreviations have been used in the
The designations employed and the presentation of present booklet:
the material in the World Drug Report do not imply ATS amphetamine-type stimulants
the expression of any opinion whatsoever on the
EMCDDA European Monitoring Centre for
part of the Secretariat of the United Nations con-
Drugs and Drug Addiction
cerning the legal status of any country, territory, city
or area, or of its authorities or concerning the delimi- Europol European Union Agency for Law
tation of its frontiers or boundaries. Enforcement Cooperation
Countries and areas are referred to by the names HBV hepatitis B virus
that were in official use at the time the relevant data HCV hepatitis C virus
were collected.
HIV human immunodeficiency virus
All references to Kosovo in the World Drug Report,
LSD lysergic acid diethylamide
if any, should be understood to be in compliance
with Security Council resolution 1244 (1999). NPS new psychoactive substances
Since there is some scientific and legal ambiguity PWID people who inject drugs
about the distinctions between “drug use”, “drug
misuse” and “drug abuse”, the neutral terms “drug UNAIDS Joint United Nations Programme on
use” and “drug consumption” are used in the World HIV/AIDS
Drug Report. The term “misuse” is used only to UNODC United Nations Office on Drugs and
denote the non-medical use of prescription drugs. Crime
All uses of the word “drug” in the World Drug Report WHO World Health Organization
refer to substances controlled under the international
drug control conventions.
All analysis contained in the World Drug Report is
based on the official data submitted by Member
States to the United Nations Office on Drugs and
Crime through the annual report questionnaire
unless indicated otherwise.
5KEY FINDINGS
Drug use is associated with significant a large number of overdose deaths involving fentanyl
adverse health consequences and its analogues in 2016.
About 275 million people worldwide, which is Outside North America, with the exception of Esto-
roughly 5.6 per cent of the global population aged nia, the impact of fentanyl and its analogues is
15–64 years, used drugs at least once during 2016. relatively low.
Some 31 million people who use drugs suffer from
Many countries still fail to provide
drug use disorders, meaning that their drug use is adequate drug treatment and health
harmful to the point where they may need treat- services to reduce the harm caused by
ment. Opioids continue to cause the most harm, drugs
accounting for 76 per cent of deaths where drug use
disorders were implicated. PWID — some 10.6 One in six people suffering from drug use disorders
million worldwide in 2016 — endure the greatest received treatment for those disorders during 2016,
health risks. More than half of them live with hepa- which is a relatively low proportion that has
titis C, and one in eight live with HIV. remained constant in recent years.
Number of deaths associated with the use Some of the most adverse health consequences of
of drugs remains high drug use are experienced by PWID. A global review
of services aimed at reducing adverse health
Roughly 450,000 people died as a result of drug use consequences among PWID has suggested that only
in 2015, according to WHO. Of those deaths, 79 countries have implemented both needle and
167,750 were directly associated with drug use dis- syringe programmes and opioid substitution therapy.
orders (mainly overdoses). The rest were indirectly Only four countries were classified as having high
attributable to drug use and included deaths related levels of coverage of both of those types of
to HIV and hepatitis C acquired through unsafe interventions.
injecting practices.
Information on the availability of HIV testing and
Overdose deaths from the non-medical
use of pharmaceutical opioid use reach counselling and antiretroviral therapy remains sparse:
epidemic proportions in North America only 34 countries could confirm the availability of
HIV-testing programmes for PWID, and 17 coun-
In 2015 and 2016, for the first time in half a cen- tries confirmed that they had no such programmes.
tury, life expectancy in the United States of America There was no information on the availability of
declined for two consecutive years. A key factor was antiretroviral therapy for 162 countries.
the increase in unintentional injuries, which include
Witnessing an overdose and experiencing
overdose deaths.
a non-fatal overdose are common
In 2016, 63,632 people died from a drug overdose
Witnessing an overdose is common among those
in the United States, the highest number on record
who use heroin and/or cocaine and who inject drugs.
and a 21 per cent increase from the previous year.
This provides an opportunity to intervene and influ-
This was largely due to a rise in deaths associated
ence the outcome of the situation (for example, in
with pharmaceutical opioids, including fentanyl and
the administration of naloxone in the case of opioid
fentanyl analogues. This group of opioids, exclud-
overdose) and whether it proves to be fatal.
ing methadone, was implicated in 19,413 deaths in
the country, more than double the number in 2015. Many people who use heroin and/or cocaine and
Evidence suggests that Canada is also affected, with who inject drugs also report that they have
62
experienced a non-fatal overdose. Non-fatal over- highest level ever: an estimated 1,410 tons. After
doses can leave drug users with significant health falling during the period 2005–2013, global cocaine
problems and have also been shown to be associated manufacture rose by 56 per cent during the period
with a subsequent fatal overdose, with the risk of 2013–2016. The increase from 2015 to 2016 was
death increasing with the number of prior non-fatal 25 per cent. The total area under coca cultivation
overdoses. worldwide in 2016 was 213,000 ha, almost 69 per
Prisoners are at higher risk for infectious cent of which was in Colombia.
diseases but are poorly served Global seizures are still dominated by can-
People in prison and other closed settings are at a nabis but sharp increases are reported for
much greater risk of contracting infections such as other drugs
tuberculosis, HIV and hepatitis C than the general Despite declining in 2016, cannabis continues to
population, but access to treatment and prevention be the drug seized in the greatest quantities world-
programmes is often lacking. Even where such pro- wide, followed by coca/cocaine-related substances
grammes are available, they are not necessarily of and opioids. Both the quantity of ATS and of
the same standard as those provided in the com- cocaine seized worldwide reached a record level in
munity. The lack of access to prevention measures 2016. The sharpest increases in the quantities of
in many prisons can result in the rapid spread of drugs intercepted worldwide in 2016 were reported
HIV and other infections. for plant-based NPS, which rose sevenfold, mainly
People who use heroin are exposed to a severe risk due to seizures of kratom. The quantity of synthetic
of death from overdose after release from prison, NPS seized worldwide, by contrast, saw a marked
especially in the first two weeks. Such deaths are decline of more than 50 per cent in 2016, mainly
related to a lowered tolerance to the effects of heroin due to a decline in the quantities of phenetalyamines
use developed after periods of relative abstinence, and synthetic cannabinoids seized.
including during incarceration. However, released Effect of the crackdown on darknet drug
prisoners are rarely able to access overdose manage- dealers is not yet clear
ment interventions, including prevention
medications such as naloxone, or treatment for sub- In July 2017, police forces from several countries
stance dependence, including methadone. worked together to take down the largest drug-trad-
ing platform on the darknet, the part of the “deep
Afghan opium poppy cultivation drives
record opiate production
web” containing information that is only accessible
using special web browsers. Before it was closed,
Total global opium production jumped by 65 per AlphaBay had featured more than 250,000 listings
cent from 2016 to 2017, to 10,500 tons, easily the for illegal drugs and chemicals. It had had over
highest estimate recorded by UNODC since it 200,000 users and 40,000 vendors during its exist-
started estimating global opium production at the ence. The authorities also succeeded in taking down
beginning of the twenty-first century. The total area the trading platform Hansa, described as the third
under opium poppy cultivation worldwide increased largest criminal marketplace on the dark web.
to almost 420,000 ha in 2017. More than 75 per
cent of that area is in Afghanistan. It is not yet clear what effect the closures will have.
According to an online survey in January 2018, 15
Overall seizures of opiates rose by almost 50 per per cent of those who had used darknet sites for
cent from 2015 to 2016. The quantity of heroin purchasing drugs said that they had used such mar-
seized globally reached a record high of 91 tons in kets less frequently since the closures, and 9 per cent
2016. Most opiates were seized near the manufac- said they had completely stopped. However, more
turing hubs in Afghanistan. than half did not consider themselves to have been
A notable increase has been seen in affected by the closures.
cocaine manufacture
Although the scale of drug trafficking on the dark-
Global cocaine manufacture in 2016 reached its net remains limited, it has shown signs of rapid
7WORLD DRUG REPORT 2018
growth. Authorities in Europe estimated that drug
sales on the darknet from 22 November 2011 to 16
February 2015 amounted to roughly $44 million
per year. However, a later study estimated that, in
early 2016, drug sales on the darknet were between
$14 million and $25 million per month, equivalent
to between $170 million and $300 million per year.
8INTRODUCTION
This booklet constitutes the second part of the World as illustrative. Information on witnessing an over-
Drug Report 2018. It provides a global overview of dose or personally experiencing a non-fatal overdose
the latest estimates of and trends in drug use and is also presented. A review of the availability and
drug supply, as well as of several cross-cutting issues levels of coverage of core interventions (particularly
related to the world drug problem. Such issues com- needle and syringe programmes and opioid substi-
prise the health impact of drug use, including trends tution therapy) to help prevent the spread of HIV
in drug use disorders, problem drug use as reflected and HCV among PWID is also included. Finally,
in treatment demand and estimates of the number the booklet contains a global overview of the latest
of people who inject drugs (PWID) and of those estimates of and trends in cultivation, production
living with HIV and hepatitis. and trafficking of illicit drugs, including on the
Internet, using the darknet.
The present booklet also examines the global extent
of deaths attributable to drug use, with recent trends
in overdose deaths in some countries being presented
Global deaths directly caused by the use of drugs have been increasing
168,000
deaths
2015
105,000
deaths
2000 +60%
Source: UNODC analysis based on WHO, Disease burden and mortality estimates, Global Health Estimates 2015: deaths by cause,
age, sex, by country and by region, 2000–2015.
9GLOBAL OVERVIEW OF DRUG DEMAND AND SUPPLY A. Extent of drug use 2
Fig. 1 Global trends in estimated number of
A. EXTENT OF DRUG USE people who use drugs, 2006–2016
Annual prevalence among population
8
Number of people who use drugs
350
aged 15–64 years (percentage)
More than a quarter of a billion
7 300
people use drugs globally
6 5.6 275
It is estimated that in 2016 some
5.2 275 million
5.2 5.2 people
5.2 5.3 250 255
5 4.9 4.9 4.6 4.8 5.0 240 243 246 247
200 208 211 203 210 226
(millions)
worldwide had used drugs at least once in the pre-
4 (range: 204 million to 346 million).
vious year
3 150
Corresponding to 5.6 per cent of the global popu-
2 15–64 years (range: 4.2 to 7.1 per cent),
lation aged 100
or approximately
1 0.6 1 of every 18 people. The actual 50 28.0 27.3 27.1 27.1 27.3 27.4 27.4 28.7 29.5 30.5
number0 of people who use drugs increased by 20 26.0
0
million people from 2015 to 2016. This change is
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
the consequence of an increase in the global number
Prevalence
of cannabis of to
users and, people who
a lesser use drugs
extent, changes in Number of people who use drugs
the methodology used to producedrug
Prevalence of people with thisuse disorders
estimate. 1 Number of people with drug use disorders
However, caution is required in interpreting trends Source: UNODC, responses to the annual report questionnaire.
because of the wide uncertainty intervals for the Note: Estimates are for adults (aged 15–64 years) who used drugs
estimates. in the past year.
Some 31 million people worldwide suffer Fig. 2 Global trends in the estimated annual
from drug use disorders prevalence of drug use and people
with drug use problems, 2006–2016
Annual prevalence among population
Of concern is the fact that an estimated one in nine 8
Number of people who use drugs
350
aged 15–64 years (percentage)
people who use drugs (11 per cent) suffer from drug
7
use disorders, meaning that their drug use is harmful 300
to the point where they may experience drug 6 5.6
5.2 5.2 5.2 5.2 5.3 250
dependence and/or require treatment. This 5 4.9 4.9 4.6 4.8 5.0
(millions)
200 208 21
amounted to an estimated 30.5 million people 4
worldwide in 2016 (range: 16.7 million to 44.4 3 150
million), or 0.62 per cent (range: 0.34 to 0.91 per 2 100
cent) of the global population aged 15–64 years. An
1 0.6 50 28.
increase of 1 million people from 2015 to 2016, 26.0
this mainly reflects a global increase in the number 0 0
2006
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
of users of opiates, as well as an increase in the
number of users of cocaine. Prevalence of people who use drugs Numbe
Evidence of increasing cannabis use Prevalence of people with drug use disorders Numbe
in some subregions Source: UNODC, responses to the annual report questionnaire.
Cannabis remained by far the most widely con- Note: Estimated percentage of adults (aged 15–64 years) who
used drugs in the past year.
sumed drug worldwide in 2016, with 192.2 million
past-year users, corresponding to 3.9 per cent of the
global population aged 15–64 years. High annual national surveys in most countries in those two
prevalence rates of cannabis use continue in West regions and more evidence is needed. Cannabis use
and Central Africa (13.2 per cent), North America also continues to increase in North America, and
(12.9 per cent) and Oceania (11.0 per cent). Experts many countries in Latin America also report an
in many countries in Africa and Asia perceived an increase in use. Cannabis use remains high in West-
increase in cannabis use, although there is a lack of ern and Central Europe, with use stabilizing in
information on the extent of drug use based on high-prevalence countries, while several other coun-
tries that historically have had a low prevalence of
1 See the online methodology section of the present report. cannabis use are now reporting an increase.
11WORLD DRUG REPORT 2018
Cannabis use among young people Global annual prevalence of cannabis use
among the general population, aged 15–64
In most countries, canna-
years and among students aged 15–16 years,
bis is the drug most widely
used, both among the gen-
2016
Annual prevalence (percentage)
Annual prevalence (percentage)
eral population and among
youth. A global estimate, 88
produced for the first
time by UNODC, based on 192.2 13.8 66 5.65.6
available data from 130 million million 3.93.9
countries, suggests that in 44
2016 13.8 million young
people (mostly students) 22
aged 15–16 years used
cannabis at least once over 00
the previous 12 months, General population Young people General
General population
Generalpopulation(aged
population (aged15-64…
(aged 15–64
15-64…years)
equivalent to 5.6 per cent aged 15-64 years aged 15–16 years Students
Students (aged
Students(aged15-16
(aged15–16years)
15-16 years)
of the population in this Sources: UNODC, annual report questionnaire data and
age range. Annual use of cannabis in 15–16 year old people was other government reports.
slightly higher than among the general population aged 15–64
Note: the estimate of cannabis use in the last year in young
years (3.9 per cent in 2016). However, caution is required as error people aged 15–16 years is based on school surveys in most
margins around these two estimates overlap. countries, thus the use of the term ‘students’.
In most countries, cannabis is the most widely used corresponding to 0.7 per cent of the global popula-
drug, both among the general population and tion aged 15–64 years. The prevalence of past-year
among young people. A global estimate, produced use of opioids among the population aged 15–64
for the first time by UNODC, based on available years is high in North America (4.2 per cent) and
data from 130 countries, suggests that, in 2016, Oceania (2.2 per cent). Among users of opioids,
13.8 million young people (mostly students) aged 19.4 million were past-year users of opiates (heroin
15–16 years used cannabis at least once in the pre- and opium), corresponding to 0.4 per cent of the
vious 12 months, equivalent to 5.6 per cent of the population aged 15–64 years, with high prevalence
population in that age range. Annual use of cannabis rates of past-year use of opiates in Central Asia and
in 15-16 year old people was slightly higher than Transcaucasia (0.9 per cent), Eastern and South-
among the general population aged 15-64 years (3.9 Eastern Europe (0.7 per cent) and North America
per cent in 2016). However, caution is required as (0.8 per cent).
error margins around these two estimates overlap. Misuse of pharmaceutical opioids
Opioids are responsible for most of the is a growing concern
negative health impact of drug use
The misuse of pharmaceutical opioids such as
While cannabis is the most widely used drug glob- tramadol is reported in many countries in Africa
ally, opioids are responsible for most of the negative (particularly West and North Africa) and in some
health impact of drug use. For example, opioids countries of the Near and Middle East. This is
accounted for 76 per cent of deaths from drug use reflected in the number of people in treatment for
disorders in 2015.2 There were an estimated 34.3 tramadol-related problems and the number of
million past-year users of opioids (persons who use tramadol overdose deaths reported in some countries.
opiates and persons who use prescription opioids The high level of misuse of pharmaceutical opioids
for non-medical purposes) globally in 2016, remains a major concern in North America, a
subregion that has seen a resurgence in heroin use
in the past four years, particularly in the United
2 WHO, Disease burden and mortality estimates, Global
Health Estimates 2015: deaths by cause, age, sex, by country
States of America. Coupled with the use of fentanyl
and by region, 2000–2015. Available at www.who.int/. and its analogues, the interlinked epidemic of
12GLOBAL OVERVIEW OF DRUG DEMAND AND SUPPLY A. Extent of drug use 2
prescription opioids and heroin has taken a heavy base paste, previously confined to cocaine-manu-
toll, especially in terms of the high number of facturing countries, has spread to many countries
reported fatal overdoses associated with their use. in South America.
There are also increasing signs of misuse of Non-medical use of benzodiazepines in
pharmaceutical opioids in Western and Central combination with prescription opioids is
Europe, as reflected, for example, in the increasing a growing problem
proportion of people entering treatment services for
non-medical use of pharmaceutical opioids in the While global estimates of the non-medical use of
subregion. While not at the same level as in North prescription drugs are not available, such misuse
America, overdose deaths related to fentanyl and its remains quite widespread, particularly among indi-
analogues have also been reported in Western and viduals practicing polydrug use. The non-medical
Central Europe. use of prescription drugs such as prescription stim-
ulants and benzodiazepines, in combination with
Amphetamines are one of the most prescription opioids, is reported to be a growing
worrying threats of drug use in East and problem in many countries. Of misused prescription
South-East Asia drugs, the non-medical use of benzodiazepines
In 2016, an estimated 34.2 million people world- remains the most common: approximately 60 coun-
wide, or 0.7 cent of the population aged 15–64 tries3 have ranked benzodiazepines among the three
years, used amphetamines in the past year. The high- most commonly misused substances, and some coun-
est annual prevalence of use of amphetamines among tries report higher prevalence rates for their use than
the population aged 15–64 years was in North for many other substances. Benzodiazepines are also
America (2.0 per cent), followed by Oceania (1.3 frequently reported in fatal overdose cases involving
per cent). It is not possible to construct a specific opioids.
estimate of use of amphetamines in East and South- Trends in drug treatment are
East Asia due to the chronic lack of data in the consistent with changing patterns
subregion, but many countries in that subregion of drug use in different regions
consider methamphetamine use to be one of the
most worrying threats of drug use. There are also Globally, the extent to which people in need of drug
concerns that an increasing number of countries are treatment actually receive it remains limited. In
reporting methamphetamine use, especially among 2016, as in previous years, an estimated one in six
opioid users in West Asia. “Ecstasy” is used by 0.4 people who had drug use disorders received treat-
per cent of the global population aged 15–64 years, ment. Despite limitations, information about people
but its spread across most regions has been striking in treatment for drug use can provide useful insight
in recent years, during which time there has also into trends and geographical variations with respect
been an increasing trend in “ecstasy” use in Western to drug use disorders. However, this information
and Central Europe, as well as Latin America. should be interpreted with caution because treat-
ment numbers reflect not only demand for treatment
Indications of an increase in cocaine use in (the number of people seeking help) but also the
the Americas extent of the provision of treatment (depending on
The use of cocaine remains concentrated in North government willingness to finance treatment
America and South America, where, respectively, services).
1.9 per cent and 0.95 per cent of the population Most people in drug treatment in Africa, the Ameri-
aged 15–64 years are past-year users, and in Oceania cas and Oceania are being treated for cannabis use.
(1.7 per cent) and Western and Central Europe (1.2 In all regions except Africa, an increasing proportion
per cent). Globally, an estimated 18.2 million people of the drug treatment provided is related to cannabis
used cocaine in 2016, or 0.4 per cent of the popu- use. Although cannabis has consistently been the
lation aged 15–64 years. There are indications of an
increase in cocaine use in many countries in North 3 Based on responses to the annual report questionnaire by
and South America. In addition, the use of cocaine Member States in 2015 and 2016.
13WORLD DRUG REPORT 2018
Fig. 3 Trends in the proportion of primary drug of use in drug treatment admissions, by region,
2003, 2009 and 2016
Proportion of treatment (percentage) 100 Other drugs
90 Amphetamine-type stimulants
80 Cocaine
70 Opioids
60 Cannabis
50
40
30
20
10
0
2003
2009
2016
2003
2009
2016
2003
2009
2016
2003
2009
2016
2003
2009
2016
2003
2009
2016
2003
2009
2016
North Latin America
North Latin Africa
Africa Asia
Asia Eastern
Eastern and Western
and Western and Oceania
America and the and
America America South-Eastern
South- andCentral
Central
Caribbean
the Europe
Eastern Europe
Europe
Caribbean
Source: UNODC, responses to the annual report questionnaire. Europe
most common drug of use among those receiving Women with drug use disorders are
drug treatment in Africa, treatment for opioid use underrepresented in treatment
disorders is increasing in the region. This trend may
Although one in three drug users is a woman, women
be an indication that ongoing trafficking of heroin
continue to account for only one in five people in
and pharmaceutical opioids in transit through Africa
treatment. The proportion of females in treatment
to other destinations has produced a worrying spillo-
tends to be higher for tranquillizers and sedatives
ver effect on drug use within Africa. Opioids remain
(approximately one in three treatment admissions
a major concern in Europe and Asia, especially in
in most subregions of the Americas and Europe)
Eastern and South-Eastern Europe, where two of
than for other substances. This reflects the fact that
every three people in drug treatment are there for
although men are three times as likely to use can-
opioid use disorders.
nabis, cocaine or amphetamines, women are more
Cocaine continues to be a drug of concern among likely to use tranquillizers and sedatives for non-
those receiving treatment in Latin America and the medical purposes. People in treatment for drug use
Caribbean, in particular, where one third of those disorders related to opioids and cocaine tend to be
in treatment for drug use disorders are being treated older: in their early thirties on average. By contrast,
for cocaine use, although that proportion has been those in treatment for cannabis use disorders tend
declining. Cocaine use disorders are reported as the to be younger: in their early twenties on average.
primary reason for drug treatment, albeit to a lesser
extent, in North America and Western and Central
Europe as well. In North America, treatment pri- B. HEALTH CONSEQUENCES
marily for cocaine use disorders has been declining OF DRUG USE
in relative importance, while the proportion of those
in treatment for opioid use disorders has increased. The main focus of this section are the health-related
In the United States, between 2004 and 2014, the aspects of the use of drugs, such as injecting drug
number of admissions related primarily to the use use, HIV and HCV acquired through unsafe inject-
of cocaine declined by 65 per cent, from 248,000 ing practices, as these are responsible for the greatest
to 88,000 individuals, and treatment for the use of burden of disease, in terms of mortality and disabil-
opiates increased by 51 per cent, from 323,000 to ity, associated with the use of drugs.4, 5 While opioids
490,000 individuals. There is a higher proportion
of treatment for the use of ATS in Asia and Oceania 4 Institute for Health Metrics and Evaluation, Global
Burden of Disease Data. Available at www.healthdata.org/.
than in other regions.
5 5 World Drug Report 2017 (United Nations publica-
tion, Sales No. E.17.XI.6).
14GLOBAL OVERVIEW OF DRUG DEMAND AND SUPPLY B. Health consequences of drug use 2
corresponding to 0.22 per cent (range: 0.17 to 0.30
Cocaine base paste in per cent) of the global population aged 15–64 years.
South America This estimate is based on the most recent and high-
Traditionally, the use of cocaine base paste had
est quality information currently available to
mostly been confined to Colombia and Peru, but UNODC. It does not imply that there has been a
over the past decade its use has gradually spread change in the global number of PWID compared
further south, to Argentina, Brazil, Chile and Uru- with those published in previous editions of the
guay. Cocaine base paste is a derivative of coca leaf World Drug Report. Based on data from 107 coun-
with a high potential for harmful use and depend-
ence. However, information on the patterns of use,
tries, the estimate covers 88 per cent of the global
health effects and options for effective treatment is population aged 15–64 years.
currently limited.a
The extent of injecting drug use is less certain or
Tighter restrictions on the sale of, and access to, unknown in some subregions due to the paucity of
the chemical precursors used in the manufacture
of cocaine hydrochloride is one of the reasons for
data: in the Caribbean, information is available only
the spread of the use of cocaine base paste to many for Puerto Rico; for all of Oceania, there are data
countries in South America. Cocaine base paste is a for Australia and New Zealand only; while for
derivative of coca leaf produced as an intermediate Africa, data are available for countries comprising
product in the preparation of cocaine hydrochlo- 58 per cent of the population aged 15–64 years, and
ride. It is a form of “smokable cocaine” of high
toxicity with a greater potential for dependence
for the Near and Middle East, only 17 per cent of
than cocaine hydrochloride, and is now a matter that population.
of concern in South America as it can cause severe
The subregions where the largest numbers of PWID
psychological and physical disorders.
reside are Eastern and South-Eastern Europe, with
As is the case for treatment of all psychostimulants, 17 per cent of the global total number of PWID and
there is currently no established pharmacological
treatment for cocaine use disorders. Information
where the prevalence of injecting drug use is highest
regarding the appropriate treatment for cocaine at 3.8 times the global average; North America, with
base paste dependence is therefore limited. 17 per cent of the global total of PWID and where
the prevalence of injecting drug use is 2.5 times the
a Antonio Pascale and others, Cocaine Base Paste Con-
global average; and East and South-East Asia, with
sumption in South America: A Review of Epidemiologi-
cal and Medical-Toxicological Aspects (Washington, D. 30 per cent of the global total of PWID, but where
C., Organization of American States, Inter-American the prevalence of injecting drug use is relatively low
Drug Abuse Control Commission, 2015). and is below the global average.
Almost half of all PWID worldwide in 2016 were
are responsible for most of the negative health impact estimated to reside in just three countries: China,
of drug use, in regions where opioid use is less the Russian Federation and the United States.
common, the use of other substances such as cocaine Although these three countries combined account
and amphetamines (both injecting and non-injecting for just 27 per cent of the global population aged
use) is also associated with adverse health conse- 15–64 years, together they are home to 45 per cent
quences. There is also increasing awareness of the of the world’s PWID, an estimated 4.8 million
health risks associated with the use of NPS, although people.
in terms of the magnitude of the problem they are
In addition to the estimates presented here, another
small. Furthermore, in many subregions, the non-
study6 providing national, regional and global esti-
medical use of benzodiazepines has been associated
mates of PWID and the prevalence of HIV among
with overdose deaths that also involved opioids.
PWID was published in The Lancet Global Health
Almost 11 million people worldwide in 2017 (see the box, entitled “Injecting drug use
injected drugs in 2016
6 Louisa Degenhardt and others, “Global prevalence of
The UNODC/WHO/UNAIDS/World Bank joint injecting drug use and sociodemographic characteristics and
prevalence of HIV, HBV, and HCV in people who inject
estimate of the number of PWID in 2016 is 10.6 drugs: a multistage systematic review”, The Lancet Global
million (range: 8.3 million to 14.7 million), Health, vol. 5, No. 12 (2017), pp. e1192–e1207.
15WORLD DRUG REPORT 2018
Fig. 4 Regional patterns in injecting drug use and HIV among people who inject drugs, 2016
35.0
Number of PWID Scale
Prevalence (percentage) of HIV among people who inject drugs
Number of PWID
2 million
30.0 100,000
South-West Asia
Number of PWID
25.0 living with HIV
Eastern and
South-Eastern Europe
20.0
Global
15.0
Africa
West and
Central Europe
10.0
South
Asia East and Central Asia and
South-East Asia Transcaucasia
5.0 Latin America and
the Caribbean North America
Near and Middle East
Oceania
0.0
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4
Prevalence (percentage) of injecting drug use among those aged 15–64 years
Source: UNODC, responses to the annual report questionnaire; progress reports of UNAIDS on the global AIDS response (various
years); the former Reference Group to the United Nations on HIV and Injecting Drug Use; and published peer-reviewed articles
and government reports.
Note: The outer circle represents the number of PWID, and the inner circle represents the number of PWID living with HIV. Regions and
subregions are coloured: green (Africa), blue (Americas), orange (Asia), yellow (Europe) and pink (Oceania). Data presented for Oceania are
for Australia and New Zealand only.
and HIV: a comparison of global estimates”). That Unsafe injecting practices, including the sharing of
study also presented data on PWID disaggregated contaminated needles and syringes, is a major route
by gender and age and estimated that approximately for the transmission of both HIV and HCV among
one in five PWID are women and a little over one PWID. In addition, those who acquire HIV and
in four are younger than 25 years of age. Informa- HCV through unsafe injecting practices can trans-
tion on the gender disaggregation of PWID was mit the diseases to others, for example, through
available for 91 countries (40 countries in Europe, sexual transmission. HCV is more readily spread
21 in Asia, 6 in the Americas, 2 in Oceania and 22 than HIV through injecting. Studies among health-
in Africa) and an age breakdown for PWID was care workers in the United States (using hospital
available for 72 countries (30 countries in Europe, data on needle-stick injury) have estimated that the
16 in Asia, 5 in the Americas, 1 in Oceania and 20 probability of transmission of HCV per exposure
in Africa). to a contaminated syringe is between 5 and 20 times
higher than for the transmission of HIV.8
PWID are among the most marginalized and stig-
matized people who use drugs. They are exposed to One in eight people who inject drugs
specific risk behaviours and risky environments and is living with HIV
experience a broad spectrum of adverse social and
health consequences. Homelessness and incarcera- Outside sub-Saharan Africa, PWID accounted for
tion are common, as is engagement in risk behaviours 20 per cent of new HIV infections in 2015.9 Fur-
such as casual unprotected sex, using a needle-
8 Elijah Paintsil and others, “Survival of hepatitis C virus
syringe after use by someone else and involvement in syringes: implication for transmission among injection
in sex work.7 drug users”, Journal of Infectious Diseases, vol. 202, No. 7
(2010), pp. 984–990.
9 UNAIDS, Ending AIDS: Progress Towards the 90–90–90
7 Ibid. Targets (Geneva, 2017).
16GLOBAL OVERVIEW OF DRUG DEMAND AND SUPPLY B. Health consequences of drug use 2
thermore, the number of newly infected PWID nated needles and syringes is an important route for
worldwide each year has been on the rise, increasing the spread of HCV worldwide. Of the total of 1.7
by one third, from 114,000 new cases in 2011 to million new HCV infections worldwide in 2015,
152,000 cases in 2015.10 This contrasts with the 23.0 per cent (390,000 people) were attributable to
estimated 11 per cent decline in new HIV infections current injecting drug use.14 Of deaths worldwide
among adults in general (more precisely, among in 2015 due to cancer and cirrhosis of the liver asso-
people aged 15 years and older) that occurred ciated with HCV infection, 31.5 per cent were
between 2010 and 2016.11 attributable to a history of injecting drug use.15
The joint UNODC/WHO/UNAIDS/World Bank HCV infection is highly prevalent among PWID,
2016 estimate of the prevalence of HIV among as every second PWID is living with HCV. The joint
PWID is 11.8 per cent, suggesting that 1.3 million UNODC/WHO/UNAIDS/World Bank estimate
PWID are living with HIV. This estimate is based for 2016 for the prevalence of HCV among PWID
on the reporting of the prevalence of HIV among is 51.9 per cent; in other words, 5.5 million people
PWID from 119 countries, covering 94 per cent of who inject drugs are living with HCV. This estimate
the estimated global number of PWID. For PWID is based on the reporting of the prevalence of HCV
living with HIV, co-infection with HCV is highly among PWID from 96 countries, covering 91 per
prevalent, at 82.4 per cent.12 cent of the estimated global number of PWID.
By far the highest prevalence of HIV among PWID The higher risk of the spread of HCV among PWID
is in South-West Asia and in Eastern and South- who are women is of particular concern. A study
Eastern Europe, with rates that are, respectively, 2.4 conducted among 1,868 PWID in Australia,
and 1.9 times the global average. Together, those Canada, the Netherlands and the United States esti-
two subregions account for 49 per cent of the total mated that women who inject drugs have a 38 per
number of PWID worldwide living with HIV. cent higher risk of contracting HCV than their male
Although the prevalence of HIV among PWID in counterparts. This higher risk does not seem to be
East and South-East Asia is below the global aver- related to different practices in the sharing of
age, 24 per cent of the global total of PWID living syringes, which is a significant risk factor for HCV,
with HIV reside in that subregion. An estimated 53 but is associated with other factors, including genetic
per cent of PWID living with HIV worldwide in factors, and differences in access to prevention
2016 (662,000 people) resided in just three coun- services.16
tries (China, Pakistan and the Russian Federation), The joint UNODC/WHO/UNAIDS/World Bank
which is disproportionately large compared with global estimate for 2016 for the prevalence of
the percentage of the world’s PWID living in those HBV17 among PWID is 7.5 per cent; in other
three countries (35 per cent). words, an estimated 0.8 million PWID are living
with HBV.
Injecting drugs is a major route for
transmission of the HCV virus
The burden of disease (mortality and morbidity)
among PWID resulting from HCV is greater than
Burden of Disease Study 2013”, The Lancet Infectious Dis-
from HIV.13 Unsafe injecting by sharing contami- eases, vol. 16, No. 12 (2016), pp. 1385–1398.
14 WHO, Global Hepatitis Report 2017 (Geneva, 2017).
10 UNAIDS, Get on the Fast-Track: The Life-cycle Approach 15 Ibid.
to HIV (Geneva, 2016).
16 Aryan Esmaeili and others, “The effect of female sex on
11 Ending AIDS: Progress Towards the 90–90–90 Targets. hepatitis C incidence among people who inject drugs:
12 Lucy Platt and others, “Prevalence and burden of HCV results from the International Multicohort InC3 Collabora-
co-infection in people living with HIV: a global systematic tive”, Clinical Infectious Diseases, vol. 66, No. 1 (2018), pp.
review and meta-analysis”, Lancet Infectious Diseases, vol. 16, 20–28.
No. 7 (2016), pp. 797-808. 17 The HBV prevalence estimate is intended to refer to active
13 Louisa Degenhardt and others, “Estimating the burden of infection (HBsAg), rather than anti-HBc, which indicates
disease attributable to injecting drug use as a risk factor for previous exposure. However, it is not always possible to dif-
HIV, hepatitis C, and hepatitis B: findings from the Global ferentiate that in the data reported to UNODC.
17WORLD DRUG REPORT 2018
Injecting drug use and HIV: a comparison of global estimates
Given the hidden and stigmatized nature of injecting drug Comparison of estimates of (a) numbers of PWID
use, it is extremely challenging to arrive at accurate and valid and (b) numbers of PWID living with HIV, selected
population size estimates for PWID and the prevalence of HIV countries, 2015
among PWID in a given country. Aggregating national data
3.0
China (638,000)a
and producing regional and global estimates is even more chal- (a) Comparison of number of PWID
Russia (415,000)a
United Republic of Tanzania (311,000)
lenging, given the gaps in data at the country level. Numerous
United States
2.5
methods are employed, including respondent-driven sampling,
(660,000)a
capture-recapture, the treatment multiplier or unique object
multiplier methods, network-scale up, census and enumeration, 2.0
Brazil (660,000)
and general population surveys to generate such estimates. Each
method has its own advantages and disadvantages, relies on 1.5
0.5
particular theoretical assumptions that may not fully reflect the
Number (millions) - Study by Dagaenhardt and co-authors
Italy (196,000)
0.4
real situation, may be logistically difficult to implement, or may
1.0
not yet have been fully validated.a Estimating the prevalence of 0.3
HIV among PWID is further complicated by selection bias and the 0.2
difficulty of recruiting a representative sample. The prevalence 0.5 0.1
of HIV among PWID can vary considerably between geographi- 0.0
0.0 0.1 0.2 0.3 0.4 0.5
cal locations within a country, thus making the calculation of a 0.0
0.0 0.5 1.0 1.5 2.0 2.5 3.0
national estimate challenging.
0.7
In 2017, Degenhardt and co-authors published country, regional (b) Comparison of number of PWID living with HIV
Indonesia (54,000) Brazil (447,000)
and global population size estimates for PWID and the preva-
United Republic of Tanzania (85,000)
0.6
lence of HIV among PWID.b Their global estimate for the number
China (156,000)
of PWID in 2015 was 3.8 million higher than the corresponding 0.5 United States (137,000)
joint UNODC/WHO/UNAIDS/World Bank estimate, and their esti-
mated number of PWID living with HIV was 1.25 million higher. 0.4
The methodologies used by Degenhardt and co-authors and the 0.10
joint UNODC/WHO/UNAIDS/World Bank estimates were broadly 0.3 0.08
consistent. The selection of country estimates was based on a
0.06
comparable grading of the quality of the available national esti- 0.2
0.04
mates. In both cases, a population-weighted average approach
0.02
was used to determine regional and global estimates and to 0.1
0.00
infer estimates for countries for which no data were available. 0.00 0.02 0.04 0.06 0.08 0.10
In the study by Degenhardt and co-authors, PWID population 0.0
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
size estimates were identified for 83 countries, and the preva-
Number (millions) - World Drug Report 2017
lence of HIV among PWID was identified for 108 countries.
UNODC identified estimates of PWID population size for 107 Source: World Drug Report 2017 (comprising the responses to the
countries and prevalence of HIV among PWID for 118 countries. annual report questionnaire, progress reports of UNAIDS on the
Degenhardt and co-authors conducted a systematic review of global AIDS response (various years), the former Reference Group
to the United Nations on HIV and Injecting Drug Use, and pub-
peer-reviewed and grey literature before UNODC conducted an lished peer-reviewed articles and government reports); and Louisa
exhaustive annual search of the scientific literature for countries Degenhardt and others, “Global prevalence of injecting drug use
for which data were not reported to UNODC, or were of insuf- and sociodemographic characteristics and prevalence of HIV, HBV,
ficient quality, and also conducted a global consultation with and HCV in people who inject drugs: a multistage systematic
experts over the prior four years. Where multiple high-quality review”, The Lancet Global Health, vol. 5, No. 12 (2017), pp.
e1192–e1207.
studies on PWID were available for a country, Degenhardt and
co-authors pooled the estimates through meta-analysis. For Note: The estimated number of PWID and number of PWID living with
HIV are for the 15–64 years age category.
the prevalence of HIV, if there were multiple estimates avail- a The difference between the estimates produced by the two studies.
able for a given country, Degenhardt and co-authors pooled
the estimates published in the four years previous to the most For approximately one third of the countries (25), the PWID
recent estimate available. UNODC generally selected the most size estimates presented in the study by Degenhardt and co-
recent estimates from studies of the highest quality, giving due authors were retained from the previous global systematic
consideration to the definition of injecting, sample size and review published 10 years ago, in 2008.c PWID population size
geographical coverage. estimates were not updated for some countries that account for
a large share of PWID: Brazil, China, India, Italy and the Russian
18GLOBAL OVERVIEW OF DRUG DEMAND AND SUPPLY B. Health consequences of drug use 2
Coverage of core interventions to
prevent spread of HIV and HCV among
Federation. Estimates of the prevalence of HIV among
PWID remains poor and insufficient
PWID was included for 108 countries, using estimates
The coverage of core interventions to help prevent
retained from the 2008 review for 12 of those countries,
including Brazil and Argentina. the spread of HIV and HCV among PWID in most
countries remains too low to be effective.18 Core,
More recent data on injecting drug use have become
available for the Russian Federation, China and Italy since
science-based interventions for the prevention of
the 2008 review and were published in the World Drug HIV are, in order of priority: needle and syringe
Report 2017. The estimates, which used indirect meth- programmes that provide sterile injecting equip-
ods of estimation, were officially reported to UNODC or ment; opioid substitution therapy to reduce
UNAIDS but were not otherwise available in the public dependency on opioids and hence decrease the fre-
domain.
quency of injecting; HIV testing and counselling,
A direct comparison is made, at the country level, of which is an important gateway into treatment and
the number of PWID and PWID living with HIV, in order
to identify those countries for which there are the larg-
care; and antiretroviral therapy to reduce the viral
est differences between the estimates of the World load and the transmission of HIV.19 For effective
Drug Report 2017 and the study by Degenhardt and HCV prevention, key interventions are needle and
co-authors. syringe programmes and opioid substitution therapy
The methodology to determine regional and global esti- coupled with HCV treatment to substantially reduce
mates and imputing data for countries with missing the ongoing HCV transmission in the communi-
information was based on the same approach in both ty.20, 21 In particular, needle and syringe programmes
studies and has not produced tangible discrepancies.
A large part of the discrepancy in regional and global
and opioid substitution therapy can be especially
estimates is due to the differences in national data for effective for both HIV and HCV prevention when
a handful of countries. they are implemented together with high levels of
There are important policy implications that arise from coverage among PWID (see table 1).22, 23, 24
the differences in the regional estimates put forward
by the two data sets. The study by Degenhardt and 18 Sarah Larney and others, “Global, regional, and country-
co-authors shows the highest prevalence of HIV among level coverage of interventions to prevent and manage HIV
PWID living with HIV in Latin America, whereas the esti- and hepatitis C among people who inject drugs: a systematic
mates of the World Drug Report 2017 point to Eastern review”, The Lancet Global Health, vol. 5, No. 12 (2017),
Europe as the region of greatest concern. From a global pp. e1208–e1220.
perspective, regional data on PWID and PWID living with 19 WHO, UNODC, UNAIDS Technical Guide for Countries to
HIV are crucial to prioritize efforts to support national Set Targets for Universal Access to HIV Prevention, Treatment
and Care for Injecting Drug Users: 2012 Revision (Geneva,
institutions and non-governmental organizations to
WHO, 2012).
provide prevention and treatment services. Thus, defin-
20 Katy M. E. Turner and others, “The impact of needle and
ing the most recent and methodologically sound set of
syringe provision and opiate substitution therapy on the
information is vital to ensuring that global efforts are incidence of hepatitis C virus in injecting drug users: pool-
properly targeted where they are most needed. ing of UK evidence”, Addiction, vol. 106, No. 11 (2011),
pp. 1978–1988.
a Abu S. Abdul-Quader, Andrew L Baughman and Wolf- 21 Peter Vickerman and others, “Can needle and syringe pro-
gang Hladik, “Estimating the size of key populations: grammes and opiate substitution therapy achieve substantial
current status and future possibilities”, Current Opinion reductions in hepatitis C virus prevalence? Model projec-
in HIV and AIDS, vol. 9, No. 2 (2014), pp. 107–114. tions for different epidemic settings”, Addiction, vol. 107,
No. 11 (2012), pp. 1984–1995.
b Louisa Degenhardt and others, “Global prevalence of
22 Louisa Degenhardt and others, “Prevention of HIV infec-
injecting drug use and sociodemographic characteristics tion for people who inject drugs: why individual, structural
and prevalence of HIV, HBV, and HCV in people who and combination approaches are needed”, The Lancet, vol.
inject drugs: a multistage systematic review”, The Lancet 376, No. 9737 (2010), pp. 285–301.
Global Health, vol. 5, No. 12 (2017), pp. e1192–e1207.
23 Natasha K. Martin and others, “Combination interventions
c Bradley M. Mathers and others, “Global epidemiology to prevent HCV transmission among people who inject
of injecting drug use and HIV among people who inject drugs: modeling the impact of antiviral treatment, needle
drugs: a systematic review”, The Lancet, vol. 372, No. and syringe programs, and opiate substitution therapy”,
9651 (2008), pp. 1733–1745. Clinical Infectious Diseases, vol. 57, Suppl. No. 2 (2013), pp.
S39–S45.
24 Turner and others, “The impact of needle and syringe
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