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Drugs, bugs and the things that unite them

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  • 1. Drugs, bugs and the things that unite them. A former ethnographer's view of drug policy and public health. Jean-Paul Grund, PhD CVO-Addiction Research Center, Utrecht Department of Epidemiology, Municipal Health Service, The Hague Summer Institute on Alcohol, Drugs and Addiction, University of Amsterdam, 15-07-2008, Amsterdam, The Netherlands
  • 2. The Replacement Speaker’s Dilemma • My presence today is more determined by the odds than intent • What to Present? • What do I want to convey? • Who is the audience and what have other speakers told them? • “Do something with your past ethnographic work”
  • 3. (My) Ethnographic Timeline • • • • • • • • • 1960s Cannabis, psychedelics, opium and speed 1970s Street Heroin culture developed in major Dutch cities – From injecting to chasing 1980s House addresses and Cocaine – 1981: My first practice: the Rotterdam Junkie Union – Activism, and needle exchange – 1985: Outreach and “collective” needle exchange – 1988: Research – Observations of heroin and cocaine users – Rituals of regulation – From needle sharing to drug sharing (Frontloading) – Rocking up cocaine: cooked cocaine 1990s Back to the streets – Increased repression of until then tolerated house addresses in neighborhoods – Platform Zero next to Central Railway Station – From chasing to basing – From self produced “cooked coke” to “crack” 1993 UCONN, USA 1995 International Harm Reduction Development Program at OSI/Soros 1999 Research: evaluation of needle exchange in CEE & Russia; Roma, drugs & HIV risks 2001 UNAIDS Policy Advisor; consultant to Yale Liquid Drugs Study 2005 Back to base: research in NL
  • 4. Today’s Timeline • A short history of wit & bruin • 25 years of cocaine smoking: a history of unanticipated and unintended consequences • A case of serendipity that illustrates the complex relationship of drug policy and risk behaviors • Exercise: Drug injection in Russia • Drug use and social context in CEE • On interventions (what to do with all that knowledge)
  • 5. Problem Drug Use in the Netherlands • Drugs: (1960s: Amphetamine, Opium); Heroin (1971); Cocaine (± 1980) • B4 1980: City center street drug markets in Amsterdam (capital), Rotterdam (harbor)… • After 1980: diffusion into low income neighborhoods & smaller towns; “House Address” market/scenes • 1990s: Back to the Streets (diffuse street markets) • 2000s: Mobile Phones (meetings, home delivery) • Mode of administration: – 1960s: IDU (white, div. background) – 1970s: shift to smoking (IDUs: white, Chasers: Surinamese, Moroccan) – 1980 – present: smoking dominates
  • 6. Mode of Drug Administration Opiates
  • 7. Mode of Drug Administration Cocaine
  • 8. Cocaine-Hydrochloride Cocaine-Base
  • 9. Cocaine Smoking in the Netherlands Example: Rotterdam • 1980s: – Cocaine hydrochloride sold at house addresses; consumed on the spot by smoking (majority) or injecting (small minority) – Users cooked C-HCL into C-B themselves – Majority chased cocaine-base – Part of social interaction within constraints of house address – Collective use, social ritual in relaxed café-like atmosphere Shift to non-IDU use • 1990s: – 1989: “Smoking over glass,” – Around 1990: crackdowns on house addresses – February 1990: first observation of “cooked coke” at Central Railway Station; Lighter & Antenna pipes. – No one knew where to buy “crack” – Individual use, quick pull from pipe in (often hostile) public places
  • 10. From self produced “wit” (white) to “cooked coke” (crack) • A market environment adjusting to a changing social policy • Cooked cocaine as an adaptive respons to increased repression (closure of house addresses), resulting in more users on the streets • Sold for very pragmatic reasons: – "You don't have to prepare it.“ – "It is ready for smoking." – "It's a gain of time." "It is not so conspicuous when you don't have to prepare before smoking.“ – "You don't have to search for a place to cook the stuff anymore.“ – "You don't need a spoon and ammonia.“ • Pushed cocaine HCL out of the street markets; wiped out preparation ritual; • result: decreased self-regulation, increased cocaine-related morbidity and problems
  • 11. Frontloading… …or the case of the Serendipitous researcher Frontloading or Syringe-Mediated-Drug-Sharing
  • 12. Definition of Serendipity • Serendipity (noun): That quality which, through good fortune and sagacity*, allows a person to discover something good while seeking something else. * Sagacity (noun): personal alertness, awareness, and understanding; sagacious (adjective): having or showing understanding and the ability to make good judgments; wise
  • 13. Field work 1988 • Publications on HIV among IDUs in USA • Needle sharing identified as risk behavior • Observations at house addresses: – Few occurrences of needle sharing in Rotterdam – Drugs often shared, social lubricants • Both among smokers and injectors
  • 14. Mode of administration by place of use
  • 15. Sharing drugs and mode of administration
  • 16. Drug sharing techniques of IDUs
  • 17. Field note of Frontloading “Richard puts the spoon in front of him, empties the heroin package in the spoon and adds some lemon and water. Meanwhile Chris opens two injection swabs and puts them on the rim of the ash-tray. When Richard is ready he nods, which Chris takes as a sign to light the swabs. Richard now holds the spoon above the flame to boil the contents. Chris carefully watches the spoon and says: "I hope it's enough that we feel it." It takes more then 2 minutes to dissolve the heroin. Then Richard puts in the cocaine almost immediately. Cotton is used to make a filter, and Richard draws the cocktail in the syringe barrel. Richard also divides the cocktail. He puts the needle back on his syringe. Chris gives him his syringe after removing the needle. Richard inserts his needle in Chris' syringe, eyeballs the amount of liquid drug and devides it. He compares each’s content holding the two syringes side by side. In one of them is a little more. That one he gives to Chris. ”
  • 18. Frontloading injectable drugs
  • 19. Frontloading • Syringe-Mediated-Drug-Sharing (Frontloading, backloading) is an important route of HIV and other viral transmission • The technique of frontloading and similar techniques are known in many countries • Frontloading observed in the Bronx, Los Angeles, Baltimore, South Florida, Barcelona, Spain, Basel, Bern and Zürich (1993) • Backloading documented in New York, San Francisco and Denver in the USA, in London, Great Britain and in Barcelona, Spain (1993) • Frontloading is the most efficient and honest way to split a certain amount of drugs in two or more portions • "We share everything; social benefit, food, dope, etc." • Drug Sharing serves both instrumental and symbolic purposes
  • 20. Synopsis • Introduction of heroin, 1971; cocaine in 1980 • Emergence of chasing heroin and cocaine and related decrease of IDU • From chasing to basing • Syringe-Mediated-Drug-Sharing • Social context of use: both protection and risk • Drug use as a social ritual • Impact of policy (street vs. house address-based markets) on Risk Environment (Rhodes, 2002) • Drug, Set & Setting (Zinberg, 1982)
  • 21. Questions, remarks, discussion!
  • 22. Exercise: Drug Injection in Russia What do you observe in the following sequence?
  • 23. What did you see? • Write a fieldnote (5 min) • Discuss in groups of 4-6 (5 min) • Report back to plenary + discussion (20 min)
  • 24. Drug Injection in Russia & Central Eastern Europe
  • 25. Drug Use Soviet Style: Do It Yourself!
  • 26. Tradition of Self Preparation of Drugs
  • 27. “Samagon” Revisited: Tradition of Self Preparation of IV Drugs • • • • Poland: “Kompot” Czech,Slovak: (“Braun”) “Piko” Hungary: “Poppy” Russian/FSU: “Cheornaya” “Vint” Strong Opiate Cocktails, Containing Codeine, Morphine, Heroin a.o. Opium Alkaloids “Jeff” Strong Psychostimulants: Methamphetamine Methcathinone,
  • 28. Collective Drug Preparation & Injecting, Friendship Networks, © Jean-Paul Grund 2001 & HIV Transmission
  • 29. Frequency of Group Injecting among Russian Syringe Exchange Participants1 N. N. N=236 Pskov N=205 R-N-D N=199 St. Petersb. N = 236 Volgograd N = 221 Total N=1,097 30 Days Prior to SEP Use(%) Group Injecting in Last 30 days Before Interview: Never 9 5 13 4 15 9 11 2 • Never 1-3 Times/Month-Less 12 27 14 Inject inWeek 10 16 10 Groups 14% 13 Once a 10 6 10 2-6 Times a Week 31 31 32 29 20 29 O c regular 13 14 23 19 • Group use is nae a Day 18occurrence 61% 18 More than Once a Da y / Al most Ever y Da y 21 8 17 23 37 22 11 36 13 31 4 5 20 15 17 28 10 12 7 8 6 26 32 22 20 5 7 19 16 33 14 14 10 26 17 18 – 2 - 6 times a week 26% Last OnceDuring SEP Use (%) – 30 Days to several times a day/almost every day 35% Never 14 1-3 Times/Month-Less 11 Once a Week 10 2-6 Times a Week 26 Once a Day 20 More than Once a Day / 19 Almost Every Day Totals may not equal 100% due to rounding or Clearly, Using in Groups is Normative Behavior among Russian IDUs. 1 missing data.
  • 30. Group Injecting, Rostov Na Donu
  • 31. Group Injecting, Rostov Na Donu
  • 32. Group Injecting, Volgograd
  • 33. Group Injecting, Volgograd
  • 34. Injection-Related HIV Risk Behaviors of Russian Syringe Exchange Participants1 Last 30 days Before SEP Use Collective use of Works S-M-D-S 82% 58% Last 30 days B4 Interview 73% 48%. The Russian risk environment, results in a very high prevalence of collective drug paraphernalia use and Syringe-Mediated-Drug-Sharing
  • 35. Social Setting of the First Hit, Ukraine “Who was present at your first injection?”* Company % Friends or good acquaintances 80 Person I did not know very well 20 Sexual partner 17 Stranger 7 Alone 5 * More than one answer was possible.
  • 36. Social Setting of the First Hit , Ukraine “Who gave you the first injection?” by gender (%) 64 Friend, acquantance 55 67 13 Self-made 4 15 8 Sexual partner 32 3 6 Drug dealer 2 7 5 Running body 4 5 1 O ther persons 3 3 0 10 20 Men 30 40 Women 50 60 All 70 80
  • 37. On interventions (what to do with all that knowledge)
  • 38. What not to do…
  • 39. Rely on obsolete treatment concepts and indiscriminate law enforcement…
  • 40. Detoxification at Narcological Dispensary, Kaliningrad
  • 41. When Substitution Treatment is Unavailable
  • 42. State Repression vs. Community Integration
  • 43. IDUs’ Relationships with Law Enforcement and other Agencies of State Control “The relations with the police are good, they do a lot of mutual work.” (Psychologist @ N.D. South Russia)
  • 44. IDUs’ Relationships with Law Enforcement
  • 45. IDUs’ Relationships with Law Enforcement
  • 46. Ignore that drug injecting is a behavior that cuts across communities…
  • 47. Injecting Drug Use is not a Population Characteristic, but a Behavioral One, Overlapping Various Vulnerable Populations • • • • Many Occasional Users Sex work Gay Community National & Ethnic Minorities, e.g. Russians in the Baltics; Roma throughout CEENIS • Prisoners
  • 48. …especially in prison!
  • 49. HIV prevalence in prisoners, Russian Federation, 1998-2001 1.000.000 900.000 800.000 2.500 N. HIV+ N. Tested 873.587 833.071 Rate/100,000 2.038 2.000 706.935 700.000 600.000 1.500 500.000 405.787 1.006 400.000 1.000 300.000 200.000 500 358 100.000 0 802 113 1998 2.979 1999 8.789 8.271 0 2000 2001
  • 50. Registered HIV infections, Baltic states, 1987-2002* 1600 1400 Estonia Latvia Lithuania 1200 1000 800 600 400 200 0 8 19 7 8 19 8 8 19 9 9 19 0 9 19 1 9 19 2 9 19 3 9 19 4 9 19 5 9 19 6 9 19 7 9 19 8 9 19 9 0 20 0 0 20 1 0 20 2 Outbreak in Alytus prison camp, August 2002
  • 51. New HIV & AIDS Cases in Lithuania, 1988 - August 20, 2002 400 344 Alytus Prison Camp: 284 Cases  350 300 250 200 HIV AIDS 150 100 65 66 52 72 31 50 11 1 81 11 51 4 92 11 1 12 5 8 3 6 9 7 ug us t2 00 2 20 01 A 20 00 19 99 19 98 19 97 19 96 19 95 19 94 19 93 19 92 19 91 19 90 19 89 19 88 0 18
  • 52. The Solution of the Prison Department & Lithuanian AIDS Center
  • 53. What to do? “The most effective responses to the epidemic grow out of people’s action within their own community and national context.” Handbook for Legislators on HIV/AIDS, Law and Human Rights (UNAIDS/IPU, 1999)
  • 54. Substitution Treatment Outreach Work Needle Exchange Programs Secondary Exchange
  • 55. Slide:Courtesy of S. Strathdee
  • 56. Not the individual IDUs, but Networks • IDU networks organized around exchange of critical commodities (e.g. drugs) • Secondary syringe distribution taps into existing exchange patterns • Drugs, HIV travel along natural links in drug using networks • So should syringes and harm reduction information
  • 57. Drug Use Characteristics of Russian Syringe Exchange Participants N = 1,076 N. N. Pskov R-N-D St. Petersb. Volgograd N = 236 N = 201 N = 199 N = 221 N = 219 Age First IDU1 (Mean/SD) Total N = 1,076 19 (4) 21 (5) 21 (5) 18 (3) 19 (4) 20 (4) < 3 years 3+ – 6 years 6+ – 10 years >10 years 22 33 33 12 47 31 10 12 18 22 25 35 43 27 16 14 26 41 26 6 30 32 23 15 Powder Heroin Amphetamine 47 9 53 61 5 24 96 9 90 4 59 20 Reported Secondary Exchange (%) 40 46 40 43 48 44 Years Injecting1 (%) Almost half of Russian Syringe Exchange Participants reported Secondary Exchange (40-48%), whether the Drug Injected (%) program encouraged it83or not. 84 Homemade opiates 15 6 21 42 1,2
  • 58. Peer Driven Interventions, Respondent Driven Sampling • Peers are rewarded to conduct the same tasks as outreach workers; – Primary incentive for participation in a series of health education sessions (accent on being taught); – Secondary incentive for engaging peers in intervention and educating them in the community (accent on teaching); • Recognizes that peers know best about peers, peers are better to convince peers than professional workers • Peer driven intervention superior to traditional outreach work intervention in HIV prevention among IDUs – Superior performance on recruitment power, representation, and in reducing risk behaviours, while being about 30 times less costly.
  • 59. BEFORE YOU GET WHATCHA WANT GOTTA GIVE THE PEOPLE WHAT THEY NEED (Public Enemy)
  • 60. Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod
  • 61. Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod
  • 62. Some quick conclusions • Drug policy has more impact on drug related harm than on drug use prevalence (eg. MOA) • Drug users are interested in their health • Drug users engage in social networks and exercise collective harm reduction action • Policy makers should better consider intended and unintended consequences of policy and interventions
  • 63. Photo Credits Black & White Photographs: © John Ranard Color Photographs: © Jean-Paul Grund
  • 64. Contact Jean-Paul Grund T: +31302381495 E: jpgrund@drugresearch.nl W3: drugresearch.nl

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