EMCDDA national focal points’ activities during the COVID-19 pandemic November 2020 Table of contents Summary ................................................................................................................................. 3 Introduction ............................................................................................................................. 5 Responses of the national focal points to the COVID-19 crisis .............................................. 6 Monitoring activities ............................................................................................................. 6 Participation in EMCDDA projects ................................................................................... 6 Ad hoc national studies .................................................................................................... 9 Expertise to stakeholders: guidelines and recommendations ........................................... 12 Dissemination of COVID-19-related information ............................................................... 14 EMCDDA briefings and other publications .................................................................... 14 Dissemination of information and provision of guidance to professionals ..................... 15 Videos ............................................................................................................................ 16 National focal points’ new activities or changes in regular service provision .................... 17 Impact of COVID-19 on the Reitox national focal points ...................................................... 17 Consequences on working conditions ............................................................................... 17 Consequences on drug-related monitoring activities ........................................................ 18 Lessons learned .................................................................................................................... 19 References ............................................................................................................................ 22 Annex .................................................................................................................................... 28 Acknowledgements ............................................................................................................... 34 2 Summary European countries have been affected by health but also economic and social challenges during the major crisis caused by the coronavirus disease (COVID-19) pandemic. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) reacted quickly to the crisis by assessing, with the support of the Reitox network, the implications of COVID-19 for people who use drugs and for drug services. The Reitox network is composed of 29 national drug observatories (i.e. those of the 27 EU Member States, Norway and Turkey), which also serve as the national focal points (NFPs) to the EMCDDA and the European Commission. Under Member States’ responsibility and EMCDDA guidance, Reitox NFPs have been responsible for (1) collecting, harmonising and analysing national information according to EMCDDA standards and providing this information to the EMCDDA; (2) monitoring and analysing national scientific, legal and policy developments; (3) coordinating and animating national drug information network(s); (4) participating actively in the EMCDDA’s tasking processes; (5) ensuring the production and dissemination of NFP outputs nationally; (6) cooperating in improving existing EMCDDA working areas; (7) cooperating in the conceptualisation of new key indicators and core datasets; (8) language checking and proofreading of EMCDDA products and publications; and (9) disseminating at the national level EMCDDA and Reitox outputs. Most of the Reitox NFPs are under the authority of their ministry of health or national public health institute and have been closely associated with COVID-19 crisis management, not only in relation to drug-related issues, but also as regards the wider scope of public health. Despite the fact that the NFPs had to adjust their work to the emerging restrictions, they led or contributed to a wide range of activities, such as carrying out risk assessments and new surveys, monitoring possible COVID-19 outbreaks among risk groups, providing guidance to stakeholders and supporting (new) drug-related services. People who use drugs are recognised as a vulnerable group and, during the COVID-19 pandemic, this group has been at risk of becoming seriously ill if infected because of their health status. Therefore, it is essential to communicate appropriate and timely advice to this group to reduce the risk of infection. In this context, the NFPs contributed to several of the EMCDDA COVID-19 special activities, such as the surveys for the Trendspotter briefings on the impact of COVID-19 on service provision and help-seeking behaviour among people who use drugs and on patterns of drug use and drug-related harms. They also contributed to the translation and dissemination of other ad hoc EMCDDA publications, such as reports on COVID-19 and EU drug markets, drug supply via darknet markets, the implications for people who use drugs, and more. The NFPs performed many extra activities that were outside their mandate as NFPs to the EMCDDA by providing expertise to different stakeholders and policymakers. They were involved in drafting, creating and providing national guidelines, disseminating information to drug users and the staff of drug services, and providing new services. The NFPs came across many challenges related to their working conditions, such as a reduction in staff, a shift of human resources to other teams involved in monitoring the pandemic and the transition to teleworking. Most of the tasks undertaken by NFPs could be conducted remotely and, despite some difficulties, such as the lack of availability of technological means, the NFPs adapted rapidly and effectively to the new conditions and did not experience an interruption to their activities. However, given that health-related matters associated with COVID-19 became a public health priority, some of the NFPs’ routine data collection, as well some surveys, were postponed from spring to autumn and a few even to 2021. Many countries might also be confronted with data challenges in the coming years, as it is not yet clear how much the COVID-19 pandemic has affected data collection and data reporting among some drug-related service providers. Despite these challenges, there was no major disruption to the work of the NFPs owing to their significant and long-running experience with systemic drug-related monitoring and reporting activities. 3 Despite the sudden change in priorities, the sustainability of the NFPs was not at all at stake. Reitox NFPs are used to risk management and are experienced in crisis communication, which were highlighted as important assets of the Reitox network during the COVID-19 pandemic. Moreover, the NFPs demonstrated a significant ability to adapt and shift their working mode, despite staff relocations, as already mentioned. During the lockdown in spring, the NFPs increased their national collaboration with different stakeholders, ensuring that more efficient data collection could be carried out during this time of crisis. The NFPs have organised online meetings and webinars at the national and international levels, involving even more local decision-makers than usual, to allow information flow and communication back and forth. The existing knowledge within the Reitox network and the opportunity that the network provided to easily exchange experiences and best practices were key during the crisis. With rapid changes in drug use patterns and other challenges, the network provided real added value for the NFPs and their national stakeholders, bringing back the added value at the EU level to the national level. As highlighted in the Reitox Development Framework (EMCDDA, 2017), to achieve a powerful collective impact, the strengthening of horizontal cooperation between NFPs and the exchange of best practices in monitoring the drug situation are key. The NFPs played a key role in acting as coordinators in this time of crisis, when human resources were scarce at different levels. It was critical that a coherent monitoring approach be maintained, that the possible overlapping of national or local surveys be limited and that the production of appropriate and timely responses be guaranteed. The leadership of the NFPs was essential and they demonstrated that they can achieve a lot, with simplified procedures, under extreme time pressure and sometimes with very scarce resources. In these times, the Reitox network has shown that it fully shares and contributes to the EMCDDA’s vision of a healthier and more secure Europe through better informed drug policies and actions, with each NFP contributing to making its own country healthier and more secure through the data it collects and analyses, and the information it provides. 4 Introduction The major public health crisis caused by the rapid spread of coronavirus disease (COVID-19) has affected European societies. Governments have had to take public health decisions, promoting social distancing, restricting movements and even imposing lockdowns, as well as socioeconomic measures. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) reacted rapidly to the crisis by assessing and publishing, in March 2020, an update on the implications of COVID-19 for people who use drugs and for drug service providers (EMCDDA, 2020a). Since the beginning of the coronavirus pandemic, the European Centre for Disease Prevention and Control (ECDC) has been collating the number of COVID-19 cases and deaths, based on reports from health authorities (ECDC, 2020). The ECDC receives data mainly through the Early Warning and Response System (EWRS), the European Surveillance System (TESSy) and the World Health Organization (WHO). In the EU Member States, ministries of health, public health institutes and other national authorities are at the front line of the crisis. Reitox is the European information network on drugs and drug addiction and it contributes to the EMCDDA’s mission, that is, to create a healthier and more secure Europe through better-informed drug policies and actions. The Reitox national focal points (NFPs) are national bodies designated by each EMCDDA participating country (the EU Member States, Norway and Turkey) to collect, analyse and report data at the national level on drugs and drug addiction to the EMCDDA. Each NFP is the primary source of national information at the EU level. Two thirds of NFPs are located in, or are closely linked to, their ministry of health or national public health institute (Figure 1). Given their institutional affiliation, most NFPs have been closely involved in COVID-19 crisis management at the national level since the beginning of the pandemic, not only as regards drug-related issues, but also in relation to general public health issues. NFPs have led, or contributed to, a wide range of activities such as risk assessment, monitoring the COVID-19 epidemic among vulnerable groups, providing guidance to stakeholders, carrying out surveys on addictive behaviours, and providing funding to reinforce services or create new ones. Figure 1 NFPs’ parent institutions Source: Reitox national focal points documentation 2020, internal. COVID-19 can cause a wide range of harms for people who use drugs. Pre-existing health problems and particular drug use behaviours can increase the risk of becoming seriously ill if people become infected (EMCDDA, 2020b). People who use drugs are an especially vulnerable group and they need to be particularly aware of the relevant advice to reduce their risk of infection. 5 The NFPs collaborated in many of the EMCDDA’s special COVID-19 activities. For instance, they contributed to the gathering of information, resulting in the following publications: in May 2020, a Trendspotter briefing entitled Impact of COVID-19 on Drug Services and Help-seeking in Europe (EMCDDA, 2020c), and, in June 2020, a Trendspotter briefing entitled Impact of COVID-19 on Patterns of Drug Use and Drug-related Harms in Europe (EMCDDA, 2020b). The NFPs also contributed to the translation and dissemination of ad hoc publications, such as EU Drug Markets: Impact of COVID-19 (EMCDDA and Europol, 2020) and a special report entitled COVID-19 and Drugs: Drug Supply via Darknet Markets (EMCDDA, 2020d). The NFPs compiled the list of activities that they performed at the national level to address the COVID-19 health crisis, between May and July 2020, for the purpose of this report. This report highlights the immediate responses taken by NFPs and describes the challenges met by the organisations and the strategies produced to overcome these challenges. In the first section, the focus is on different monitoring activities during the COVID-19 health crisis. The report also describes the responses of the NFPs, such as the provision of scientific expertise for guidelines, reports and policy recommendations, but also the dissemination of COVID-19-related information to their various audiences and the provision of new services. The report also draws attention to the impact of COVID- 19 on the NFPs as organisations, namely its consequences on working conditions and on NFPs’ monitoring activities. Finally, the last section focuses on the lessons learned so far. Responses of the national focal points to the COVID-19 crisis Monitoring activities Despite the challenges created by the pandemic, NFPs continued to actively monitor the drug situation. The NFPs have strong national monitoring systems in place and use the EMCDDA’s standardised indicator protocols for regular monitoring. In spring 2020, the EMCDDA rapidly developed several specific surveys for the COVID-19 context, to which the NFPs contributed. These were the Mini European Web Survey on Drugs (Mini-EWSD), a series of trendspotter surveys, an EU drug market analysis, a prison survey, a European Syringe Collection and Analysis Project Enterprise (Escape) study and a Trans European Drug Information (TEDI) study. Some countries also participated in different surveys that were coordinated by other international organisations and EU agencies. During this period, some countries launched special tools designed to monitor the situation during the COVID-19 health emergency. Countries developed new surveys and questionnaires and conducted new analyses based on the routine data from their monitoring systems. A few countries initiated wastewater analysis or began COVID-19 case tracking among drug users. Table 1, in the annex, includes the list of national studies and projects, with links to documents where available. Participation in EMCDDA projects Mini-EWSD: the impact of COVID-19 on patterns of drug use, harms and drug services in the European Union The EMCDDA conducted a special COVID-19 round of the European Web Survey (the Mini-EWDS) (EMCDDA, 2020e) to assess the impact of COVID-19 on people who use drugs. The survey gathered 6 information on patterns of drug use, access to health services, drug markets and the impact of COVID-19-related restrictions. Most countries participated in the survey, which was translated into 21 languages and made available between 8 and 25 May 2020. The role of the NFPs was to translate, disseminate and promote the survey among their stakeholders and networks. In addition, some of them published or are planning to publish the national figures and analysis in a chapter of a COVID-19 report or in other specific reports (i.e. Ireland, Greece, Spain (DGPNSD OEDA, 2020a), Latvia, Lithuania (1), Luxembourg and Slovenia). Around 10 600 respondents completed the online questionnaire (with around 30 questions) in one of the languages available. This contributed to the production of a comprehensive, realistic and timely picture of drug use in Europe and to the overall analysis of the situation and of the changes associated with the COVID-19 pandemic and its consequences (EMCDDA, 2020b). Trendspotter studies on the effects and implications of the COVID-19 outbreak on drug services and patterns of drug use The series of EMCDDA trendspotter studies investigated the effects and implications of the first wave of the COVID-19 outbreak on drug services and help-seeking in Europe (May 2020; EMCDDA, 2020c), and the impact on patterns of drug use and drug-related harms in Europe among people who use drugs (June 2020; EMCDDA, 2020b). The series used a mixed-method approach to investigate the situation. The trendspotter methodology is based on the triangulation of a range of rapid investigative approaches and data collection from multiple quantitative and qualitative sources with a systematic analysis incorporating the use of expert opinion (EMCDDA, 2018a). The methodology used in the COVID-19 briefings had been adapted to suit online investigation, considering the national emergency restrictions. A literature review was performed, online expert surveys were organised, the Mini-EWSD was launched (see previous paragraph) and various virtual facilitated groups were created made up of European drug professionals, researchers and representatives. In April 2020, an initial online survey was sent to the Reitox network of NFPs. One of the focus groups organised in the trendspotter study involved three NFPs, namely from Belgium, Czechia and France. A number of experts recommended by the NFPs participated in other focus groups. Many NFPs adapted the EMCDDA questionnaire and sent it to their national institutions, authorities, experts and drug-related services to provide the most reliable answers to the survey. The Austrian NFP published the national results of the questionnaire and shared them with all of its provincial networks (Horváth et al., 2020); several other NFPs also translated the trendspotter publication into their national languages and disseminated the results in this way. This exercise fostered collaboration between different organisations; for example, the Norwegian NFP completed the EMCDDA questionnaire in collaboration with the Norwegian Directorate of Health and KORUS Oslo, which have been implementing a weekly survey at municipal level since the start of the lockdown. Moreover, the completion of the questionnaire was informed by the efforts of the Norwegian Centre for Addiction Research (SERAF), which has been focusing on COVID-19 and the treatment of substance use disorders. The Polish NFP expanded on the trendspotter survey and undertook a rapid assessment on the impact of COVID-19 on drug services, drug users and the drug market. The results were published in English (Malczewski et al., 2020) and were also presented in a series of webinars, organised in June and October as a part of a national conference held in Warsaw. Moreover, the results of the survey were published in four Polish scientific journals. (1) Results were presented to the media on 22 July 2020 (Narkotikų, tabako ir alkoholio kontrolės departamentas, 2020). 7 Like its Polish counterpart, the Hungarian NFP expanded on the trendspotter survey and created a national questionnaire for drug service providers about drug use, health and social risks, and access to treatment and harm reduction services. It also included questions on changes in drug prices and availability. Following the COVID-19 outbreak, the Hungarian social system had to face more and different challenges, handle more needs and develop complex responses to food provision, shelter, daily care, asylums in lockdown, etc., while the healthcare system struggled to continue adequately providing care. Referral and admission of new cases in many units was stopped (psychiatry, addiction, HIV/hepatitis C virus (HCV) treatment, etc.) to avoid overload and nosocomial infections due to the pandemic. The NFP produced a detailed report of the results of the questionnaire and a briefing, both of which are currently under assessment by decision-makers and have not yet been published. Several other NFPs conducted ad hoc monitoring activities, which also contributed to the analysis of the state of drug services, such as a rapid assessment among treatment centres in Belgium to assess the impact of the pandemic on this specialised sector and on drug users. The results indicated that there had been changes in the services offered, gave an insight into the demands of the service users, those receiving opioid substitution treatment and COVID-19 patients among the drug users, and highlighted the specific requirements of the services. The results were shared with the authorities and the drug treatment services (in French and Dutch). In France, the French Monitoring Centre for Drugs and Drug Addiction (OFDT) undertook qualitative monitoring based on the feedback from its TREND scheme and network in seven large cities (Bordeaux, Lille, Lyon, Marseille, Metz, Paris and Rennes). The results of this rapid assessment among harm reduction facilities were published online in French and English (Gérome and Gandilhon, 2020a, 2020b). In Slovenia, the NFP also summarised the results of a rapid assessment of the situation in a report published in Slovenian on the website of the National Institute of Public Health (NIJZ) entitled, in English, The impact of the COVID-19 pandemic on treatment and provision services for drug users and on the drug market in Slovenia (Drev, 2020). In Cyprus, an assessment of changes in treatment demand and treatment provision was performed; the results, which provided information on the mode of treatment provision and working hours of services, were published on the website of the Cyprus National Addictions Authority. The Irish NFP undertook a rapid assessment of the impact of COVID-19 through the Department of Health and Social Care. During May and June, staff in the National Drug Treatment Reporting System, based at the Irish NFP, telephoned all of the treatment services that were submitting treatment demand data to ascertain the impact of the pandemic on service provision. In Romania, in addition to compiling answers to the trendspotter questionnaire, the NFP also processed the available national treatment demand data (based on the treatment demand indicator) from January to March for a special analysis. In addition, in Italy, an ad hoc monitoring activity was carried out focusing on changes in treatment requests and the provision of treatment and involving a group of social- and healthcare staff of treatment centres. Furthermore, in Finland, the NFP performed a survey among drug service providers on the changes in service provision and demand. The NFP has conducted this survey every 5 weeks since the beginning of the epidemic, collecting data for the Ministry of Social Affairs and Health, which is responsible for service monitoring during the crisis. As a result, a blog was published and a publication will possibly be drafted. Drug market survey A joint publication of the EMCDDA and Europol analyses the effect that the COVID-19 pandemic has had on EU drug markets, for the main drug types (cannabis, heroin, cocaine, amphetamines and new psychoactive substances), including on demand, production, trafficking and availability (EMCDDA and Europol, 2020). For this publication, the EMCDDA conducted a targeted online survey in April 2020. 8 The Reitox network supported the data collection by strengthening collaboration with supply reference experts working in different services such as in the police. Prisons: cooperation on monitoring and reporting In settings in which people are gathered in enclosed environments such as in prisons, there is a heightened risk of person-to-person and droplet transmission of pathogens such as coronavirus. People in prisons also have a greater underlying burden of disease and worse health conditions than the general population (WHO, 2020a, 2020b). The EMCDDA collects data on prison settings to closely monitor this population. Fifteen countries have ensured the participation of prison experts in this survey up to now. In Luxembourg, the NFP ran an adapted version of the European questionnaire on drug use among prisoners, including several COVID-19-related questions, until the end of August 2020 in their national closed prisons among their complete inmate populations. Moreover, the Hungarian NFP conducted a national prison facility survey in September, which included COVID-19-related issues. The results of this study are expected to be available in the coming months. EU research projects Other international surveys and ad hoc studies were conducted in which NFPs played an active role in the drafting, piloting and creation, translation, review and dissemination of the surveys and data collection. For instance, the French NFP is piloting the Escape project (EMCDDA, 2019). An analysis of the substances injected using syringes during the lockdown period was done in Czechia with the participation of the Czech NFP. The Lithuanian, Latvian and Finnish NFPs are also collaborating in the project jointly with other partners from other countries. The TEDI (EMCDDA, undated) survey in Luxembourg fostered collaboration between partners of harm reduction, health education and drug checking services on the implementation of a survey on the impact of COVID-19 on recreational drug user habits. The NFP participated in testing the pilot, promoting the survey at the national level and reviewing the report. In addition to data collection for the EMCDDA, several NFPs have also completed the United Nations Office on Drugs and Crime (UNODC) special survey on a global initiative to improve knowledge on COVID-19’s impact on crime and drugs in June 2020. Ad hoc national studies In addition to data collection for the EMCDDA, and their usual monitoring activities as part of their mandates, NFPs also performed specific national studies or contributed to surveys initiated by other partners during spring 2020. One of the four strategic objectives of the Reitox Development Framework, a document that defines the main priorities of the Reitox network in fulfilling its roles and functions in the future, is to strengthen the role of the NFPs in supporting decision-making and action at the national level (EMCDDA, 2018b). This national work may also support horizontal cooperation between NFPs by giving them an opportunity to exchange best practices, to increase collaboration with each other and to support each other in having a powerful collective impact. In addition, it helps to increase the external visibility of the Reitox network as a whole by developing new products. Focus on services In Luxembourg, the NFP published, in collaboration with the National Statistics Institute (STATEC Luxembourg) and the national drug coordinator, a so-called ‘Flash COVID-19’ report on the impact of COVID-19 on drug users and national drug treatment and harm reduction service providers. It is a six- 9 page factsheet/report. Another study has been conducted by the Luxembourg NFP in collaboration with the national drug coordinator and directors of drug treatment and harm reduction services, focusing on the evaluation of low-threshold services and their newly implemented low-threshold opioid substitution treatment offer. The study aims to assess the impact of COVID-19 and the national measures implemented on high-risk drug use clients attending national harm reduction and supervised drug consumption facilities. A short written questionnaire was distributed to participants between July and September 2020. Results should published by the end of 2020. In Lithuania, between March and May 2020, the NFP monitored alcohol and drug-related non-fatal overdoses by comparing 2019 data with the situation during the quarantine period and also compared changes in treatment demands (NTAKD, 2020a). The Greek NFP is assisting the national coordinator in the creation and dissemination of a questionnaire targeting drug professionals, focusing on their experience during the COVID-19 health emergency. The data collection is still ongoing. In Estonia, the NFP is very closely monitoring the effects of COVID-19 by collecting data from harm reduction services, treatment centres and other services. In March 2020, the Dutch NFP conducted an initial rapid assessment of the impact of the COVID-19 measures on harm reduction facilities and their target groups. This rapid assessment was then repeated twice (in April and June). The study was done in collaboration with Mainline (a harm reduction service provider) and MDHG (a medical social service for drug users) (Van der Gouwe et al., 2020). The results were discussed with the Ministry of Health, and best practices were distributed to stakeholders in various ways. In October 2020, a fourth rapid assessment was conducted. In Czechia, the NFP has been actively monitoring the changes in treatment and harm reduction provision and has issued and published two rapid assessment reports (National Monitoring Centre for Drugs and Addiction, 2020a,b); a third rapid assessment report is in preparation. The rapid assessment reports aimed to inform national stakeholders of the impact of COVID-19 on the drug scene and on drug-related services. They were presented and endorsed in a session of the Government Council for Drug Policy Coordination on 25 June 2020. In addition, the Czech NFP monitored the interventions carried out by addiction services providers through an online facility survey, with COVID-19-related questions added to the routine questions. Focus on web surveys A new study on the impact of COVID-19 on addictive behaviours was conducted in Portugal. The Portuguese NFP launched three online surveys: the first related to alcohol and medication use, the second to the use of the internet and video games, and the third to the use of cannabis. The results of the surveys are available on the website of the General Directorate for Intervention on Addictive Behaviours and Dependencies (SICAD) and were disseminated through social networks. In the Netherlands, there are several national studies under way. The first survey investigated if cannabis users in the country changed their consumption patterns after the introduction of the coronavirus measures in mid-March and, if so, the reasons for change. A total of 1 563 participants were included in this study (Vercoulen et al., 2020). The (preliminary) findings received a lot of media attention, as these findings showed that 4 in 10 cannabis users increased their cannabis use as a result of the pandemic, mainly because of boredom, but stress and loneliness also played a role. In addition, the National Big Nightlife Survey 2020 was adapted to include COVID-19-related questions in the survey. The data collection phase lasted until the end of May (Van Miltenburg et al., 2020). The survey focused on the consequences of the measures in the first period of the lockdown in terms of the use of drugs, alcohol and tobacco among partygoers and young adults. The survey was repeated in September/October 2020. Moreover, in the Netherlands, the monitoring of internet and online apps 10