This document provides background on the speaker Jean-Paul Grund and his experience studying drug use through ethnographic research. It outlines his timeline of research from the 1960s studying cannabis, psychedelics, opium and speed through the 2000s doing research in the Netherlands. It discusses the emergence of heroin and cocaine use in the Netherlands and how the social context and drug markets influenced risk behaviors over time, such as the shift from needle sharing to drug sharing practices. It also outlines Grund's research on drug use and HIV risks in Russia and Central and Eastern Europe, including the traditions of group drug preparation and injection in those regions.

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

12. Frontloading…
…or the case of the Serendipitous researcher
Frontloading
or
Syringe-Mediated-Drug-Sharing

13. 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

14. 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

15. Mode of administration by place of use

16. Sharing drugs and mode of administration

17. Drug sharing techniques of IDUs

18. 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. ”

19. Frontloading injectable drugs

20. 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

21. 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)

22. Questions, remarks, discussion!

24. Exercise: Drug Injection in Russia
What do you observe in
the following sequence?

34. What did you see?
• Write a fieldnote (5 min)
• Discuss in groups of 4-6 (5 min)
• Report back to plenary + discussion (20 min)

36. Drug Injection in Russia
& Central Eastern Europe

37. Drug Use Soviet Style: Do It Yourself!

38. Tradition of Self Preparation of Drugs

39. “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,

40. Collective Drug
Preparation & Injecting,
Friendship Networks,
© Jean-Paul Grund 2001
& HIV Transmission

41. 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.

42. Group Injecting, Rostov Na Donu

43. Group Injecting, Rostov Na Donu

44. Group Injecting, Volgograd

45. Group Injecting, Volgograd

46. 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

47. 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.

48. 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

50. On interventions (what to
do with all that knowledge)

51. What not to do…

52. Rely on obsolete treatment
concepts and indiscriminate
law enforcement…

53. Detoxification at Narcological Dispensary, Kaliningrad

54. When Substitution Treatment is Unavailable

55. State Repression vs. Community Integration

56. 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)

57. IDUs’ Relationships with Law Enforcement

58. IDUs’ Relationships with Law Enforcement

59. Ignore that drug injecting is a
behavior that cuts across
communities…

60. 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

61. …especially in prison!

62. 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

63. 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

64. 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

65. The Solution of the Prison Department &
Lithuanian AIDS Center

67. 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)

68. Substitution Treatment
Outreach Work
Needle Exchange Programs
Secondary Exchange

69. Slide:Courtesy of S. Strathdee

70. 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

71. 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

72. 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.

73. BEFORE YOU GET
WHATCHA WANT
GOTTA GIVE
THE PEOPLE
WHAT THEY NEED
(Public Enemy)

74. Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod

75. Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod

77. 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

78. Photo Credits
Black & White Photographs:
© John Ranard
Color Photographs:
© Jean-Paul Grund

79. Contact
Jean-Paul Grund
T: +31302381495
E: jpgrund@drugresearch.nl
W3: drugresearch.nl