Substance Use & Misuse, Early Online:1–11, 2015 C 2015 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2015.978672
ORIGINAL ARTICLE
Emerging Risks Due to New Injecting Patterns in Hungary During Austerity Times
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´ 1 , Maria ´ ´ 2 , V. Anna Gyarmathy3 , Erzsebet ´ ´ Anna Tarjan Dudas Rusvai4 , Balint Treso´ 4 2 ´ ´ and Agnes Csohan 1
Hungarian Reitox National Focal Point, National Centre for Epidemiology, Budapest, Hungary; 2 Department for Communicable Diseases, National Centre for Epidemiology, Budapest, Hungary; 3 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; 4 Division of Virology, National Centre for Epidemiology, Budapest, Hungary NCE NPS OST PWID SEP
As a consequence of the massive restructuring of drug availability, heroin injection in Hungary was largely replaced by the injecting of new psychoactive substances (NPS) starting in 2010. In the following years in our sero-prevalence studies we documented higher levels of injecting paraphernalia sharing, daily injection-times, syringe reuse, and HCV prevalence among stimulant injectors, especially among NPS injectors. Despite the increasing demand, in 2012 the number of syringes distributed dropped by 35% due to austerity measures. Effects of drug market changes and the economic recession may have future epidemiological consequences. Study limitations are noted and future needed research is suggested.
National Centre for Epidemiology new psychoactive substances opioid substitution treatment people who inject drugs syringe-exchange program
INTRODUCTION
Extensive changes have taken place since 2010 in the macro risk environment of people who inject drugs (PWID) in Europe – as regards the availability of traditional and new drug types and the consequences of the 2008 economic recession – ( Friedman, Rossi, & Braine, 2009; Rhodes, 2009). These changes have had an impact on patterns of use, use-related risks and infections, and service provision targeted at this specific group. However, the extent to which all of these factors affected the PWID population has differed from country to country. One major change in the physical macro-level risk environment (Friedman et al., 2009; Rhodes, 2009) of PWID has been a radical transformation regarding the availability of injectable drugs on the market. Partly as a result of law enforcement activities (EMCDDA, 2013a, 2013b; Griffiths, Mounteney, & Laniel, 2012) between 2010 and 2011, a drastic decrease was observed in the number and quantity of heroin seizures in Europe (EMCDDA, 2013a). Nonetheless, several member states – including Hungary – that traditionally had relatively large proportion of heroin users among PWID – were experiencing not only a decrease but a serious heroin “drought” between late 2010 and early 2011 (EMCDDA, 2013a; Griffiths, et al., 2012; P´eterfi, Tarj´an, Horv´ath, Csesztregi, & Ny´ır´ady, 2014).
Keywords Injecting drugs use, new psychoactive substances, synthetic cathinones, heroin shortage, hepatitis C, syringe sharing, risk behaviors, syringe-exchange program, harm reduction, economic recession
ABBREVIATIONS:
DTC ECDC
drug-user-treatment centre European Centre for Disease Prevention and Control EMCDDA European Monitoring Centre for Drugs and Drug Addiction HBV hepatitis B virus HCV hepatitis C virus HIV Human immunodeficiency virus HNFP Hungarian Reitox National Focal Point
The authors would like to thank the efforts of the staff at the Department of Communicable Diseases and the Hepatitis and Molecular Virology Department of the NCE for data collection and laboratory analysis. Special thanks to the HNFP for collecting and providing SEP data, to the staff and the clients of SEPs and DTCs in the two sero-behavioral surveys, and to the SEPs that provided data on their client and syringe turnover to the HNFP annually. Address correspondence to Anna Tarj´an, Hungarian Reitox National Focal Point, 2-6 Albert Fl´ori´an u´ t, 1097 Budapest, Hungary; E-mail: [email protected]. +36209709008
1
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2
´ ET AL. A. TARJAN
In parallel with the heroin shortage, the rapid emergence of new psychoactive substances (NPS) became a serious concern all over the continent regarding both supply and demand, including a large expansion of the synthetic cathinone drug market (EMCDDA & Europol, 2013; Hillebrand, Olszewski, & Sedefov, 2010; UNODC, 2013; Van Hout & Bingham, 2012). According to the number of cases notified to EU Early Warning System (EMCDDA, 2013a; P´eterfi, et al., 2014), the emergence of new synthetic cathinones reached its peak in 2010 and slowed down only slightly during 2011 and 2012. Hungary belongs to the group of countries that have been greatly affected by these big events1 occurring recently in the drug market (Griffiths, et al., 2012; Hedrich, et al., 2013; P´eterfi, et al., 2014; Pharris, et al., 2011). Rapid spread of these new substances and the transformation of the injecting drug user population were facilitated – in addition to the underlying heroin shortage – by the combination of many factors: NPS’s noncontrolled status, nondetectability during police arrests, easy availability and extended accessibility by fast growing online sale, competitive and low price, high purity, intensive effects, easy preparation for injecting, possible open scene use, and perceived low risks by users due to the legal status and lack of information about either shorter or longer term consequences of either shorter or longer term consumption. (Carhart-Harris, King, & Nutt, 2011; Csak, Demetrovics, & Racz, 2013; Csak, Gyekiss, Marvanykovi, Vadasz, & Racz, 2010; Dybdal-Hargreaves, Holder, Ottoson, Sweeney, & Williams, 2013; EMCDDA & Europol, 2013; HNFP, 2011, 2012; Racz, Csak, Farago, & Vadasz, 2012; Van Hout & Bingham, 2012). Drug use was related to as a taboo in Hungary – a country from the Eastern Block in Europe – before the political change in 1989. Injecting drug use was only a sporadic phenomenon, which was characterized by the use of medical opiates and home-made poppy products. (Bajz´ath, T´oth, & R´acz, 2014; P´eterfi, et al., 2014) After the political transition in 1989 – that also brought along changes in the domestic drug market – heroin replaced home-made products and was the primary drug injected in the 1990s (Csak, et al., 2013). Amphetamine, used as an injected drug, started to spread from the 2000s (Gyarmathy, Neaigus, Mitchell, & Ujhelyi, 2009). In Hungary both use of and trafficking with substances scheduled as illicit substances have been legislated as being criminal offences (EMCDDA, 2012a). Until 2010, most PWID in Hungary injected either heroin (around 60–70%) or amphetamines 1
“Big events” – This relatively new term, introduced into the intervention literature by Friedman et al. (S. Friedman, Rossi, & Flom, 2006) refers to major events such as mega – disasters, natural, as well as manmade, famine, conflict, genocide, disparities in health, epidemics, mass migrations, economic recessions, etc. which effect adaptation, functioning, and quality-of-life of individuals as well as systems. Existential threat, instability, and chaos are major dimensions and loss of control over one’s life is experienced. The conditions necessary for a “big event” to operate (micro to macro levels; temporal ranges), to begin, to continue as realties change, and to be sustained have yet to be adequately delineated empirically as well as theoretically.
(around 30-40%) (Gyarmathy et al., 2010; HNFP, 2010; P´eterfi, et al., 2014). This picture, however, changed considerably in 2010 as reflected in the national seizure data: both the numbers and the quantities of heroin seizures significantly decreased, while those of licit synthetic cathinones and their different combinations started to increase rapidly (EMCDDA, 2014; HNFP, 2011, 2012, 2013; P´eterfi, et al., 2014). At the same time, these market changes were reflected in the drug use patterns of PWID (Hedrich, et al., 2013; P´eterfi, et al., 2014; Pharris, et al., 2011): a significant shift could be detected in our national epidemiological routine data collection systems (drug user treatment, drug use-related death, SEPs’ client data) (P´eterfi, et al., 2014). For example, data between 2009 and 2012 on PWID attending syringe-exchange programs (SEP) – which provides the most valid picture on injecting drug use trends – shows a considerable decrease (from 56% to 17%) in the proportion of heroin injectors and a highly marked increase (from 4% to 43%) in the proportion of PWID who primarily inject “other” substances mainly synthetic cathinones, while the proportion of amphetamine injectors remained stable (around 40%) (HNFP, 2013; P´eterfi, et al., 2014). The synthetic cathinone injector population consisted partly of new entrants, but at the same time a sizeable proportion of those who earlier injected amphetamines and heroin shifted to these newly emerged, licit, and cheaper substances (Csak, et al., 2013; Csak, et al., 2010; HNFP, 2011, 2012; P´eterfi, et al., 2014; Racz, et al., 2012). Our national SEP client data from 2011 and 2012 also revealed that the prevalence of NPS injecting was the highest among young PWID under the age 25 (HNFP, 2013; Tarj´an, 2012b, 2013) – those who have the least experience with safer injecting routines (Corson et al., 2013; EHRN, 2009). Qualitative data from 2011 also suggests that recently initiated PWID often start their injecting carrier with synthetic cathinones as they associate these substances with injecting (Tarj´an, 2012a). Injecting of stimulants, especially of synthetic cathinones, is associated with a higher number of daily injections (Botescu, 2012; Csak, et al., 2013; Csak, et al., 2010; Hedrich, et al., 2013; HNFP, 2012; Racz, et al., 2012). A higher number of drug injections by default leads to a higher number of sharing and reusing of syringes and injecting equipment – the primary transmission routes of HIV and HCV infections among PWID. While these structural changes in the drug market were taking place, most European countries were facing a drastically changing socio-economic macro-environment. The economic recession starting from 2008 affected PWID at (individual and community) micro level (Friedman, et al., 2009; Rhodes, 2009) regarding their cost of living, employment, homelessness but also in terms of the operation of services that are provided for them to reduce harms and prevent infections that are highly related with injecting drug use such as opioid substitution treatment (OST) and SEP. In an economic-crisis driven environment, at individual level the aforementioned easy availability, legal status, and low prices were probably appealing factors in
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EMERGING RISKS DUE TO NEW INJECTING PATTERNS IN HUNGARY DURING AUSTERITY TIMES
the preference of NPS versus traditional, controlled substances. Easy preparation of these substances for injection was also preferred by PWID with poor living circumstances, residing on streets (Tarj´an, 2012a; Van Hout & Bingham, 2012). Many countries in the field of drug use-related infectious diseases prevention programs experienced decreasing availability of funds and crisis-driven cost cutting policies at the macro-level during the post-2008 economic recession (Botescu, 2012; Hedrich, et al., 2013; Kentikelenis, et al., 2011; Paraskevis, et al., 2013; Pharris, et al., 2011). The long-term declining trend in HIV incidence among PWID in Europe has been interrupted in Greece and Romania since 2011 by serious outbreaks of HIV, which occurred against a background of high HCV prevalence (Botescu, 2012; EMCDDA & ECDC, 2012; Fotiou, et al., 2012; Hedrich, et al., 2013; Paraskevis, et al., 2013; Pharris, et al., 2011). The effects of the economic recession contributed, among others, to low service coverage of OST and decreasing coverage of and access to SEP services in the aforementioned countries, which all coincided with new drug-related infectious disease outbreaks (EMCDDA & ECDC, 2012; Hedrich, et al., 2013; Pharris, et al., 2011). Hungary has traditionally been a country with extremely low levels of HIV among PWID. Prevalence of HCV has also been considered relatively low on a national scale, with certain regional differences (EMCDDA, 2013d; HNFP, 2012, 2013). However, ecological analysis based on the characteristics of several actual populations of drug users predicts that in case the current HCV prevalence increases, the epidemiological balance may be tipped over toward an increase in the prevalence of HIV (Gyarmathy & Racz, 2010; Vickerman, Hickman, May, Kretzschmar, & Wiessing, 2010). The current epidemiological situation may change due to the mentioned micro and macro environmental changes that have been taking place in Europe in general and in Hungary in particular if adequate levels of infectious diseases prevention responses are not implemented (Cox, et al., 2009; ECDC & EMCDDA, 2011; EMCDDA, 2004; Vickerman, Martin, Turner, & Hickman, 2012; WHO, UNODC, & UNAIDS, 2013). Little is known about the characteristics and the infection-related consequences of NPS injecting in the Hungarian PWID population, and the effect of austerity measures on the access and coverage of infectious diseases prevention programs. The aim of this study was to collect and analyze available recent quantitative national and subnational data from the period of 2011–2012 regarding HCV prevalence and injecting-related risk behaviors, with a special focus on NPS injecting, and recent trends in SEP coverage and access of PWID to services. The study’s aims were to estimate the effects of the restructuring of the drug market (including heroin shortage and appearance of NPS) among PWID and how harm reduction efforts in austerity times meet the epidemiological aspects (if any) of these changes.
3
METHODS
Data from three sources: (1) a national HIV/HBV/HCV sero-prevalence study series; (2) a subnational voluntary diagnostic HIV/HBV/HCV testing program (both conducted among PWID); and (3) national SEP turnover data. The first two studies were used for the analysis of injecting patterns, associated risk behaviors and HCV infections. Due to the very low prevalence in both surveys of HIV (0%) and acute HBV (under 1.3%) throughout the examined years (HNFP, 2012), these infections were not included in this risk analysis. Low prevalences are probably because HIV has not yet spread in the PWID population, and universal vaccination against HBV was implemented in 1999 among 14-year olds. The third source of data was used to assess current responses in preventing infectious diseases among PWID. OST coverage data – another commonly used measure in infectious diseases prevention (ECDC & EMCDDA, 2011) – were excluded, since they are less relevant for a population primarily injecting stimulants. Between 2006 and 2011, the national HIV/HBV/HCV sero-prevalence study was carried out among PWID annually (with the exception of 2010) by the National Centre for Epidemiology (NCE) with consistent methodology in order to ensure comparability and the measuring of trends throughout the years. Survey variables included HIV, HBV, and HCV infections, selected sociodemographic and injecting pattern related variables (during the entire survey period), and syringe and injecting paraphernalia sharing in the past 4 weeks, time of last injection and testing uptake (after 2009), based on the recommendations of EMCDDA (EMCDDA, 2006, 2013c). In the surveys between 2006 and 2008, substances are categorized as opioids and non-opioids; and in 2009 as opioids, amphetamines, cocaine, and other drugs. Starting in 2011, data for the category “other drugs” has been collected by means of an open-ended question. Participating outpatient drug-treatment centers (DTC) or SEPs were assigned a target sample size based on the number of their PWID clients, and a consecutive sampling process (by inviting all PWID clients to participate) took place for three months in each study year until the target sample size at each location was reached. Participation was voluntary and anonymous. Participants provided their informed consent, and were offered free testing for HIV, HCV, and HBV, and confidential pre and posttest counseling, and were administered a face-to-face survey interview by a staff specifically trained for the study. Study incentive was a food voucher equivalent to HUF 2000 (EUR 6.7). Refusal rate was not recorded. However, service providers reported that only a negligible number of their clients refused to participate. For the first time in a study in Hungary, blood was collected from finger pricks and dried blood samples were used for the laboratory analysis (EMCDDA, 2006; Treso, et al., 2013). HCV blood samples were analyzed at the Hepatitis and Molecular Virology Department of the NCE, using the HCV Ab Screening ELISA kit
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´ ET AL. A. TARJAN
manufactured by DiaPro, INNOTEST HCV Ab IV kit manufactured by Innogenetics and Bioelisa HCV kit by Biokit. Anti-HCV positive results were verified by INNO-LIA HCV Score tests by Innogenetics (Treso, et al., 2013). In 2009, 676 PWID were tested in 7 DTCs and 13 SEPs, while in 2011, 666 PWID were tested in 5 DTCs and 13 SEPs. The subnational voluntary routine diagnostic HIV/HBV/HCV testing program (also coordinated by the NCE) offered testing and counseling between April 2010 and June 2013 for people who ever injected drugs and who self-reported not being screened within a year before at the participating SEPs and DTCs. Participants in this program did not receive any incentive. While the recruitment method was different from the study above, the two studies had identical biological and core questionnaire data collection methods. In 2012 in order to improve measurement precision of drug use patterns related to NPS, the category “other primarily injected drugs” was made into an open-ended question, and variables “number of injection times on the last day of injecting” and “number of reuses of the last syringe discarded” were added in this study. Comparability of data across years is very limited because participating locations varied over time and recruiting was not standardized. Results only from 2012 are presented in this paper given that the 2012 data are the most in-depth and comprehensive. During that year, 378 PWID were tested in 8 counties with the participation of 3 DTCs and 12 SEPs. Contingency tables to describe distribution, chi-square tests (or Fisher’s exact tests when warranted) with corresponding p values were used to determine significant associations, t test, and analysis of variance were applied to compare group means. Since analyses in this paper are exploratory, several associations were assessed. Syringe and paraphernalia sharing in the past 4 weeks were only assessed among those participants who reported injecting in the 4 weeks prior to the survey. A p value of 0.05 was considered significant. SPSS 16 program package was used for data management and analysis. The NCE is entitled to conduct epidemiological studies under the law 47/1997 and the Minister of Public Welfare Decree 18/1998. (VI. 3.) Since 2004, the HNFP has been annually collecting the national SEP turnover data by means of a standardized data-collection tool. This data-collection exercise involves all service providers who offer SEP services for PWID through fixed, mobile, or street outreach sites, or through syringe vending machines. Analysis of aggregate data and quality assurance has also been carried out by the HNFP (HNFP 2013). For the assessment of sterile syringe coverage in the PWID population, the latest national estimate of the PWID population was applied (HNFP, 2010). In addition, relevant qualitative data from service providers are also presented.
TABLE 1. Distribution (N) of PWID tested during the national HIV/HBV/HCV prevalence survey (2006–2011) with a valid test result for HCV by primarily injected drug type
primarily stimulant injectors primarily opioid injectors Total sample
2006
2007
2008
2009
2011
39
151
162
257
325
248
397
426
410
327
287
548
588
667
652
marily opioid injectors from 86.7% to 50%, while proportion of stimulant injectors increased from 13.3% to 50% (Table 1). In 2011, 17.1% of stimulant injectors mentioned injecting primarily NPS, typically synthetic cathinone derivatives, mephedrone (10.8%), and MDPV (6.3%). The proportion of current injectors who in the past 4 weeks reported sharing needles/syringes, and sharing any injecting equipment, respectively, also increased significantly from 25.9% to 35.9% and from 40.4% to 51.3% between 2009 and 2011 (Table 2). Considering injector groups by drug type for both these variables, the highest raise occurred among stimulant injectors for sharing any injecting equipment (from 37% to 51%; p = 0.0039). There was no significant change in the overall prevalence of HCV infection between 2006 and 2011. However, significant differences can be observed among groups by the primarily injected substance across study years. Between 2006 and 2009, primarily opioid injectors had higher HCV prevalence at about 30%, whereas in 2011 HCV prevalence was 18% among them. On the other hand, HCV was 30% among stimulant injectors in 2011 (30% among amphetamine injectors, 20% among MDPV injectors, and 40% among mephedrone injectors), which was significantly higher than both among opioid injectors that year and among stimulant injectors in prior years (Figure 1; see also Table 1 for number of tested PWID). The results of the 2012 voluntary diagnostic testing program show that both the mean number of injection times on the last day of injecting and the mean number of reuses of the last syringe were the highest among NPS injectors (5.4 and 4.1 – compared to, for example, 2.7 and 1.8 among opioid users, difference is significant) (Table
RESULTS
The national sero-prevalence study survey documented a decrease between 2006 and 2011 in the proportion of pri-
FIGURE 1. HCV prevalence (%) among PWID tested during the national HIV/HBV/HCV prevalence survey (2006–2011), by primary injected drug type and in the total sample.
5
EMERGING RISKS DUE TO NEW INJECTING PATTERNS IN HUNGARY DURING AUSTERITY TIMES
TABLE 2. Prevalence of injecting-related risk behaviors in the past 4 weeks among current PWID tested during the national HIV/HBV/HCV prevalence survey in 2009 and 2011,%; (N of PWID responding)
Syringe sharing in the total sample Syringe sharing in stimulant injectors Syringe sharing in opioid injectors Any injecting equipment sharing in the total sample Any injecting equipment sharing in stimulant injectors Any injecting equipment sharing in opioid injectors
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∗
2009
2011
25.9%(313) 25.2%(111) 26.2%(202) 40.4%(314) 36.6%(112) 42.6%(202)
35.9%(382)∗ 35.5%(245) 36.5%(137)∗ 51.3%(382)∗ 53.1%(245)∗ 48.2%(137)
significant difference compared to 2009, p < 0.05
3). Within the group of NPS injectors, the highest mean number of injecting times were detected among 4-MEC and pentedrone injectors (11.5 and 5.4), while the highest mean number of reuses of the last syringe were among MDPV and pentedrone injectors (4.9 and 3.5). Overall, 34.5% of current injectors reported sharing needles/syringes in the past 4 weeks, and 44.3% reported sharing any injecting equipment. However, both needle/syringe sharing (52.9%) and injecting equipment sharing (64%) in the past 4 weeks were the most frequent in the NPS injector group, which are significantly higher than the other substance group values (Table 3). Within the NPS group, syringe sharing and any equipment sharing were 73.3% and 66.7% among MDPV injectors, and 40.0% and 64.0% among pentedrone injectors. The prevalence of HCV infection in the overall sample was 23.2%. There were, however, significant differences across drug user groups: the highest infection prevalence was detected among NPS injectors (38.6%) and the lowest among amphetamines injectors (19.4%) (Table 3). Within the NPS group, HCV prevalence was 52.4% among pri-
marily pentedrone injectors (n = 21) and 45% among primarily MDPV injectors (n = 20). The national SEP data – after an increasing trend in previous years – show a significant and considerable reduction between 2011 and 2012 both in the number of distributed (by 35%) and returned syringes (by 36%) (Figure 2) and in the number of client contacts (by 14%). Furthermore, during this time, the mean number of distributed sterile syringes per PWID decreased from 114 to 74. According to qualitative data provided by service managers, restrictive measures had to be implemented in 2012 due to limited financial resources SEPs encountered. For example, the largest SEPs had to restrict the number of syringes given out per contact, and some SEPs had to reduce their opening hours in order to be able to maintain their service operation throughout the year. In addition, some programs had to temporarily or permanently shut down. On the other hand, demand for SEP was almost unchanged between 2011 and 2012, both considering the number of clients who used the service (3373 vs. 3357) and the number of newly registered clients (1559 vs. 1555) (Figure 2).
TABLE 3. HCV prevalence and injecting-related risk behaviors among PWID tested during the subnational voluntary diagnostic testing program in 2012, by primarily injected drug type and in the total sample Primarily injected drug type
HCV prevalence%; (N of tested PWID with a valid result) Syringe sharing in the past 4 weeks%; (N of current PWID responding) Any injecting equipment sharing in the past 4 weeks%; (N of current PWID responding) Number of injection times per day mean; (N of responding PWID) Number of reuses of the last syringe mean; (N of responding PWID) ∗
Significant differences when NPS compared to other groups p
ORIGINAL ARTICLE
Emerging Risks Due to New Injecting Patterns in Hungary During Austerity Times
Subst Use Misuse Downloaded from informahealthcare.com by University of Connecticut on 04/01/15 For personal use only.
´ 1 , Maria ´ ´ 2 , V. Anna Gyarmathy3 , Erzsebet ´ ´ Anna Tarjan Dudas Rusvai4 , Balint Treso´ 4 2 ´ ´ and Agnes Csohan 1
Hungarian Reitox National Focal Point, National Centre for Epidemiology, Budapest, Hungary; 2 Department for Communicable Diseases, National Centre for Epidemiology, Budapest, Hungary; 3 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; 4 Division of Virology, National Centre for Epidemiology, Budapest, Hungary NCE NPS OST PWID SEP
As a consequence of the massive restructuring of drug availability, heroin injection in Hungary was largely replaced by the injecting of new psychoactive substances (NPS) starting in 2010. In the following years in our sero-prevalence studies we documented higher levels of injecting paraphernalia sharing, daily injection-times, syringe reuse, and HCV prevalence among stimulant injectors, especially among NPS injectors. Despite the increasing demand, in 2012 the number of syringes distributed dropped by 35% due to austerity measures. Effects of drug market changes and the economic recession may have future epidemiological consequences. Study limitations are noted and future needed research is suggested.
National Centre for Epidemiology new psychoactive substances opioid substitution treatment people who inject drugs syringe-exchange program
INTRODUCTION
Extensive changes have taken place since 2010 in the macro risk environment of people who inject drugs (PWID) in Europe – as regards the availability of traditional and new drug types and the consequences of the 2008 economic recession – ( Friedman, Rossi, & Braine, 2009; Rhodes, 2009). These changes have had an impact on patterns of use, use-related risks and infections, and service provision targeted at this specific group. However, the extent to which all of these factors affected the PWID population has differed from country to country. One major change in the physical macro-level risk environment (Friedman et al., 2009; Rhodes, 2009) of PWID has been a radical transformation regarding the availability of injectable drugs on the market. Partly as a result of law enforcement activities (EMCDDA, 2013a, 2013b; Griffiths, Mounteney, & Laniel, 2012) between 2010 and 2011, a drastic decrease was observed in the number and quantity of heroin seizures in Europe (EMCDDA, 2013a). Nonetheless, several member states – including Hungary – that traditionally had relatively large proportion of heroin users among PWID – were experiencing not only a decrease but a serious heroin “drought” between late 2010 and early 2011 (EMCDDA, 2013a; Griffiths, et al., 2012; P´eterfi, Tarj´an, Horv´ath, Csesztregi, & Ny´ır´ady, 2014).
Keywords Injecting drugs use, new psychoactive substances, synthetic cathinones, heroin shortage, hepatitis C, syringe sharing, risk behaviors, syringe-exchange program, harm reduction, economic recession
ABBREVIATIONS:
DTC ECDC
drug-user-treatment centre European Centre for Disease Prevention and Control EMCDDA European Monitoring Centre for Drugs and Drug Addiction HBV hepatitis B virus HCV hepatitis C virus HIV Human immunodeficiency virus HNFP Hungarian Reitox National Focal Point
The authors would like to thank the efforts of the staff at the Department of Communicable Diseases and the Hepatitis and Molecular Virology Department of the NCE for data collection and laboratory analysis. Special thanks to the HNFP for collecting and providing SEP data, to the staff and the clients of SEPs and DTCs in the two sero-behavioral surveys, and to the SEPs that provided data on their client and syringe turnover to the HNFP annually. Address correspondence to Anna Tarj´an, Hungarian Reitox National Focal Point, 2-6 Albert Fl´ori´an u´ t, 1097 Budapest, Hungary; E-mail: [email protected]. +36209709008
1
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2
´ ET AL. A. TARJAN
In parallel with the heroin shortage, the rapid emergence of new psychoactive substances (NPS) became a serious concern all over the continent regarding both supply and demand, including a large expansion of the synthetic cathinone drug market (EMCDDA & Europol, 2013; Hillebrand, Olszewski, & Sedefov, 2010; UNODC, 2013; Van Hout & Bingham, 2012). According to the number of cases notified to EU Early Warning System (EMCDDA, 2013a; P´eterfi, et al., 2014), the emergence of new synthetic cathinones reached its peak in 2010 and slowed down only slightly during 2011 and 2012. Hungary belongs to the group of countries that have been greatly affected by these big events1 occurring recently in the drug market (Griffiths, et al., 2012; Hedrich, et al., 2013; P´eterfi, et al., 2014; Pharris, et al., 2011). Rapid spread of these new substances and the transformation of the injecting drug user population were facilitated – in addition to the underlying heroin shortage – by the combination of many factors: NPS’s noncontrolled status, nondetectability during police arrests, easy availability and extended accessibility by fast growing online sale, competitive and low price, high purity, intensive effects, easy preparation for injecting, possible open scene use, and perceived low risks by users due to the legal status and lack of information about either shorter or longer term consequences of either shorter or longer term consumption. (Carhart-Harris, King, & Nutt, 2011; Csak, Demetrovics, & Racz, 2013; Csak, Gyekiss, Marvanykovi, Vadasz, & Racz, 2010; Dybdal-Hargreaves, Holder, Ottoson, Sweeney, & Williams, 2013; EMCDDA & Europol, 2013; HNFP, 2011, 2012; Racz, Csak, Farago, & Vadasz, 2012; Van Hout & Bingham, 2012). Drug use was related to as a taboo in Hungary – a country from the Eastern Block in Europe – before the political change in 1989. Injecting drug use was only a sporadic phenomenon, which was characterized by the use of medical opiates and home-made poppy products. (Bajz´ath, T´oth, & R´acz, 2014; P´eterfi, et al., 2014) After the political transition in 1989 – that also brought along changes in the domestic drug market – heroin replaced home-made products and was the primary drug injected in the 1990s (Csak, et al., 2013). Amphetamine, used as an injected drug, started to spread from the 2000s (Gyarmathy, Neaigus, Mitchell, & Ujhelyi, 2009). In Hungary both use of and trafficking with substances scheduled as illicit substances have been legislated as being criminal offences (EMCDDA, 2012a). Until 2010, most PWID in Hungary injected either heroin (around 60–70%) or amphetamines 1
“Big events” – This relatively new term, introduced into the intervention literature by Friedman et al. (S. Friedman, Rossi, & Flom, 2006) refers to major events such as mega – disasters, natural, as well as manmade, famine, conflict, genocide, disparities in health, epidemics, mass migrations, economic recessions, etc. which effect adaptation, functioning, and quality-of-life of individuals as well as systems. Existential threat, instability, and chaos are major dimensions and loss of control over one’s life is experienced. The conditions necessary for a “big event” to operate (micro to macro levels; temporal ranges), to begin, to continue as realties change, and to be sustained have yet to be adequately delineated empirically as well as theoretically.
(around 30-40%) (Gyarmathy et al., 2010; HNFP, 2010; P´eterfi, et al., 2014). This picture, however, changed considerably in 2010 as reflected in the national seizure data: both the numbers and the quantities of heroin seizures significantly decreased, while those of licit synthetic cathinones and their different combinations started to increase rapidly (EMCDDA, 2014; HNFP, 2011, 2012, 2013; P´eterfi, et al., 2014). At the same time, these market changes were reflected in the drug use patterns of PWID (Hedrich, et al., 2013; P´eterfi, et al., 2014; Pharris, et al., 2011): a significant shift could be detected in our national epidemiological routine data collection systems (drug user treatment, drug use-related death, SEPs’ client data) (P´eterfi, et al., 2014). For example, data between 2009 and 2012 on PWID attending syringe-exchange programs (SEP) – which provides the most valid picture on injecting drug use trends – shows a considerable decrease (from 56% to 17%) in the proportion of heroin injectors and a highly marked increase (from 4% to 43%) in the proportion of PWID who primarily inject “other” substances mainly synthetic cathinones, while the proportion of amphetamine injectors remained stable (around 40%) (HNFP, 2013; P´eterfi, et al., 2014). The synthetic cathinone injector population consisted partly of new entrants, but at the same time a sizeable proportion of those who earlier injected amphetamines and heroin shifted to these newly emerged, licit, and cheaper substances (Csak, et al., 2013; Csak, et al., 2010; HNFP, 2011, 2012; P´eterfi, et al., 2014; Racz, et al., 2012). Our national SEP client data from 2011 and 2012 also revealed that the prevalence of NPS injecting was the highest among young PWID under the age 25 (HNFP, 2013; Tarj´an, 2012b, 2013) – those who have the least experience with safer injecting routines (Corson et al., 2013; EHRN, 2009). Qualitative data from 2011 also suggests that recently initiated PWID often start their injecting carrier with synthetic cathinones as they associate these substances with injecting (Tarj´an, 2012a). Injecting of stimulants, especially of synthetic cathinones, is associated with a higher number of daily injections (Botescu, 2012; Csak, et al., 2013; Csak, et al., 2010; Hedrich, et al., 2013; HNFP, 2012; Racz, et al., 2012). A higher number of drug injections by default leads to a higher number of sharing and reusing of syringes and injecting equipment – the primary transmission routes of HIV and HCV infections among PWID. While these structural changes in the drug market were taking place, most European countries were facing a drastically changing socio-economic macro-environment. The economic recession starting from 2008 affected PWID at (individual and community) micro level (Friedman, et al., 2009; Rhodes, 2009) regarding their cost of living, employment, homelessness but also in terms of the operation of services that are provided for them to reduce harms and prevent infections that are highly related with injecting drug use such as opioid substitution treatment (OST) and SEP. In an economic-crisis driven environment, at individual level the aforementioned easy availability, legal status, and low prices were probably appealing factors in
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EMERGING RISKS DUE TO NEW INJECTING PATTERNS IN HUNGARY DURING AUSTERITY TIMES
the preference of NPS versus traditional, controlled substances. Easy preparation of these substances for injection was also preferred by PWID with poor living circumstances, residing on streets (Tarj´an, 2012a; Van Hout & Bingham, 2012). Many countries in the field of drug use-related infectious diseases prevention programs experienced decreasing availability of funds and crisis-driven cost cutting policies at the macro-level during the post-2008 economic recession (Botescu, 2012; Hedrich, et al., 2013; Kentikelenis, et al., 2011; Paraskevis, et al., 2013; Pharris, et al., 2011). The long-term declining trend in HIV incidence among PWID in Europe has been interrupted in Greece and Romania since 2011 by serious outbreaks of HIV, which occurred against a background of high HCV prevalence (Botescu, 2012; EMCDDA & ECDC, 2012; Fotiou, et al., 2012; Hedrich, et al., 2013; Paraskevis, et al., 2013; Pharris, et al., 2011). The effects of the economic recession contributed, among others, to low service coverage of OST and decreasing coverage of and access to SEP services in the aforementioned countries, which all coincided with new drug-related infectious disease outbreaks (EMCDDA & ECDC, 2012; Hedrich, et al., 2013; Pharris, et al., 2011). Hungary has traditionally been a country with extremely low levels of HIV among PWID. Prevalence of HCV has also been considered relatively low on a national scale, with certain regional differences (EMCDDA, 2013d; HNFP, 2012, 2013). However, ecological analysis based on the characteristics of several actual populations of drug users predicts that in case the current HCV prevalence increases, the epidemiological balance may be tipped over toward an increase in the prevalence of HIV (Gyarmathy & Racz, 2010; Vickerman, Hickman, May, Kretzschmar, & Wiessing, 2010). The current epidemiological situation may change due to the mentioned micro and macro environmental changes that have been taking place in Europe in general and in Hungary in particular if adequate levels of infectious diseases prevention responses are not implemented (Cox, et al., 2009; ECDC & EMCDDA, 2011; EMCDDA, 2004; Vickerman, Martin, Turner, & Hickman, 2012; WHO, UNODC, & UNAIDS, 2013). Little is known about the characteristics and the infection-related consequences of NPS injecting in the Hungarian PWID population, and the effect of austerity measures on the access and coverage of infectious diseases prevention programs. The aim of this study was to collect and analyze available recent quantitative national and subnational data from the period of 2011–2012 regarding HCV prevalence and injecting-related risk behaviors, with a special focus on NPS injecting, and recent trends in SEP coverage and access of PWID to services. The study’s aims were to estimate the effects of the restructuring of the drug market (including heroin shortage and appearance of NPS) among PWID and how harm reduction efforts in austerity times meet the epidemiological aspects (if any) of these changes.
3
METHODS
Data from three sources: (1) a national HIV/HBV/HCV sero-prevalence study series; (2) a subnational voluntary diagnostic HIV/HBV/HCV testing program (both conducted among PWID); and (3) national SEP turnover data. The first two studies were used for the analysis of injecting patterns, associated risk behaviors and HCV infections. Due to the very low prevalence in both surveys of HIV (0%) and acute HBV (under 1.3%) throughout the examined years (HNFP, 2012), these infections were not included in this risk analysis. Low prevalences are probably because HIV has not yet spread in the PWID population, and universal vaccination against HBV was implemented in 1999 among 14-year olds. The third source of data was used to assess current responses in preventing infectious diseases among PWID. OST coverage data – another commonly used measure in infectious diseases prevention (ECDC & EMCDDA, 2011) – were excluded, since they are less relevant for a population primarily injecting stimulants. Between 2006 and 2011, the national HIV/HBV/HCV sero-prevalence study was carried out among PWID annually (with the exception of 2010) by the National Centre for Epidemiology (NCE) with consistent methodology in order to ensure comparability and the measuring of trends throughout the years. Survey variables included HIV, HBV, and HCV infections, selected sociodemographic and injecting pattern related variables (during the entire survey period), and syringe and injecting paraphernalia sharing in the past 4 weeks, time of last injection and testing uptake (after 2009), based on the recommendations of EMCDDA (EMCDDA, 2006, 2013c). In the surveys between 2006 and 2008, substances are categorized as opioids and non-opioids; and in 2009 as opioids, amphetamines, cocaine, and other drugs. Starting in 2011, data for the category “other drugs” has been collected by means of an open-ended question. Participating outpatient drug-treatment centers (DTC) or SEPs were assigned a target sample size based on the number of their PWID clients, and a consecutive sampling process (by inviting all PWID clients to participate) took place for three months in each study year until the target sample size at each location was reached. Participation was voluntary and anonymous. Participants provided their informed consent, and were offered free testing for HIV, HCV, and HBV, and confidential pre and posttest counseling, and were administered a face-to-face survey interview by a staff specifically trained for the study. Study incentive was a food voucher equivalent to HUF 2000 (EUR 6.7). Refusal rate was not recorded. However, service providers reported that only a negligible number of their clients refused to participate. For the first time in a study in Hungary, blood was collected from finger pricks and dried blood samples were used for the laboratory analysis (EMCDDA, 2006; Treso, et al., 2013). HCV blood samples were analyzed at the Hepatitis and Molecular Virology Department of the NCE, using the HCV Ab Screening ELISA kit
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4
´ ET AL. A. TARJAN
manufactured by DiaPro, INNOTEST HCV Ab IV kit manufactured by Innogenetics and Bioelisa HCV kit by Biokit. Anti-HCV positive results were verified by INNO-LIA HCV Score tests by Innogenetics (Treso, et al., 2013). In 2009, 676 PWID were tested in 7 DTCs and 13 SEPs, while in 2011, 666 PWID were tested in 5 DTCs and 13 SEPs. The subnational voluntary routine diagnostic HIV/HBV/HCV testing program (also coordinated by the NCE) offered testing and counseling between April 2010 and June 2013 for people who ever injected drugs and who self-reported not being screened within a year before at the participating SEPs and DTCs. Participants in this program did not receive any incentive. While the recruitment method was different from the study above, the two studies had identical biological and core questionnaire data collection methods. In 2012 in order to improve measurement precision of drug use patterns related to NPS, the category “other primarily injected drugs” was made into an open-ended question, and variables “number of injection times on the last day of injecting” and “number of reuses of the last syringe discarded” were added in this study. Comparability of data across years is very limited because participating locations varied over time and recruiting was not standardized. Results only from 2012 are presented in this paper given that the 2012 data are the most in-depth and comprehensive. During that year, 378 PWID were tested in 8 counties with the participation of 3 DTCs and 12 SEPs. Contingency tables to describe distribution, chi-square tests (or Fisher’s exact tests when warranted) with corresponding p values were used to determine significant associations, t test, and analysis of variance were applied to compare group means. Since analyses in this paper are exploratory, several associations were assessed. Syringe and paraphernalia sharing in the past 4 weeks were only assessed among those participants who reported injecting in the 4 weeks prior to the survey. A p value of 0.05 was considered significant. SPSS 16 program package was used for data management and analysis. The NCE is entitled to conduct epidemiological studies under the law 47/1997 and the Minister of Public Welfare Decree 18/1998. (VI. 3.) Since 2004, the HNFP has been annually collecting the national SEP turnover data by means of a standardized data-collection tool. This data-collection exercise involves all service providers who offer SEP services for PWID through fixed, mobile, or street outreach sites, or through syringe vending machines. Analysis of aggregate data and quality assurance has also been carried out by the HNFP (HNFP 2013). For the assessment of sterile syringe coverage in the PWID population, the latest national estimate of the PWID population was applied (HNFP, 2010). In addition, relevant qualitative data from service providers are also presented.
TABLE 1. Distribution (N) of PWID tested during the national HIV/HBV/HCV prevalence survey (2006–2011) with a valid test result for HCV by primarily injected drug type
primarily stimulant injectors primarily opioid injectors Total sample
2006
2007
2008
2009
2011
39
151
162
257
325
248
397
426
410
327
287
548
588
667
652
marily opioid injectors from 86.7% to 50%, while proportion of stimulant injectors increased from 13.3% to 50% (Table 1). In 2011, 17.1% of stimulant injectors mentioned injecting primarily NPS, typically synthetic cathinone derivatives, mephedrone (10.8%), and MDPV (6.3%). The proportion of current injectors who in the past 4 weeks reported sharing needles/syringes, and sharing any injecting equipment, respectively, also increased significantly from 25.9% to 35.9% and from 40.4% to 51.3% between 2009 and 2011 (Table 2). Considering injector groups by drug type for both these variables, the highest raise occurred among stimulant injectors for sharing any injecting equipment (from 37% to 51%; p = 0.0039). There was no significant change in the overall prevalence of HCV infection between 2006 and 2011. However, significant differences can be observed among groups by the primarily injected substance across study years. Between 2006 and 2009, primarily opioid injectors had higher HCV prevalence at about 30%, whereas in 2011 HCV prevalence was 18% among them. On the other hand, HCV was 30% among stimulant injectors in 2011 (30% among amphetamine injectors, 20% among MDPV injectors, and 40% among mephedrone injectors), which was significantly higher than both among opioid injectors that year and among stimulant injectors in prior years (Figure 1; see also Table 1 for number of tested PWID). The results of the 2012 voluntary diagnostic testing program show that both the mean number of injection times on the last day of injecting and the mean number of reuses of the last syringe were the highest among NPS injectors (5.4 and 4.1 – compared to, for example, 2.7 and 1.8 among opioid users, difference is significant) (Table
RESULTS
The national sero-prevalence study survey documented a decrease between 2006 and 2011 in the proportion of pri-
FIGURE 1. HCV prevalence (%) among PWID tested during the national HIV/HBV/HCV prevalence survey (2006–2011), by primary injected drug type and in the total sample.
5
EMERGING RISKS DUE TO NEW INJECTING PATTERNS IN HUNGARY DURING AUSTERITY TIMES
TABLE 2. Prevalence of injecting-related risk behaviors in the past 4 weeks among current PWID tested during the national HIV/HBV/HCV prevalence survey in 2009 and 2011,%; (N of PWID responding)
Syringe sharing in the total sample Syringe sharing in stimulant injectors Syringe sharing in opioid injectors Any injecting equipment sharing in the total sample Any injecting equipment sharing in stimulant injectors Any injecting equipment sharing in opioid injectors
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∗
2009
2011
25.9%(313) 25.2%(111) 26.2%(202) 40.4%(314) 36.6%(112) 42.6%(202)
35.9%(382)∗ 35.5%(245) 36.5%(137)∗ 51.3%(382)∗ 53.1%(245)∗ 48.2%(137)
significant difference compared to 2009, p < 0.05
3). Within the group of NPS injectors, the highest mean number of injecting times were detected among 4-MEC and pentedrone injectors (11.5 and 5.4), while the highest mean number of reuses of the last syringe were among MDPV and pentedrone injectors (4.9 and 3.5). Overall, 34.5% of current injectors reported sharing needles/syringes in the past 4 weeks, and 44.3% reported sharing any injecting equipment. However, both needle/syringe sharing (52.9%) and injecting equipment sharing (64%) in the past 4 weeks were the most frequent in the NPS injector group, which are significantly higher than the other substance group values (Table 3). Within the NPS group, syringe sharing and any equipment sharing were 73.3% and 66.7% among MDPV injectors, and 40.0% and 64.0% among pentedrone injectors. The prevalence of HCV infection in the overall sample was 23.2%. There were, however, significant differences across drug user groups: the highest infection prevalence was detected among NPS injectors (38.6%) and the lowest among amphetamines injectors (19.4%) (Table 3). Within the NPS group, HCV prevalence was 52.4% among pri-
marily pentedrone injectors (n = 21) and 45% among primarily MDPV injectors (n = 20). The national SEP data – after an increasing trend in previous years – show a significant and considerable reduction between 2011 and 2012 both in the number of distributed (by 35%) and returned syringes (by 36%) (Figure 2) and in the number of client contacts (by 14%). Furthermore, during this time, the mean number of distributed sterile syringes per PWID decreased from 114 to 74. According to qualitative data provided by service managers, restrictive measures had to be implemented in 2012 due to limited financial resources SEPs encountered. For example, the largest SEPs had to restrict the number of syringes given out per contact, and some SEPs had to reduce their opening hours in order to be able to maintain their service operation throughout the year. In addition, some programs had to temporarily or permanently shut down. On the other hand, demand for SEP was almost unchanged between 2011 and 2012, both considering the number of clients who used the service (3373 vs. 3357) and the number of newly registered clients (1559 vs. 1555) (Figure 2).
TABLE 3. HCV prevalence and injecting-related risk behaviors among PWID tested during the subnational voluntary diagnostic testing program in 2012, by primarily injected drug type and in the total sample Primarily injected drug type
HCV prevalence%; (N of tested PWID with a valid result) Syringe sharing in the past 4 weeks%; (N of current PWID responding) Any injecting equipment sharing in the past 4 weeks%; (N of current PWID responding) Number of injection times per day mean; (N of responding PWID) Number of reuses of the last syringe mean; (N of responding PWID) ∗
Significant differences when NPS compared to other groups p
