Prevalence of high-risk drug use and coverage of opioid substitution treatment and needle and syringe programs in Lithuania in 2015-2016: A multi-method estimation study.

BACKGROUND AND OBJECTIVES: In Lithuania, injecting heroin and other illicit opioids has dominated high-risk drug use since about 2000. More recently, patients have reported a high-risk use of amphetamines. Newly diagnosed HIV cases among people who inject drugs peaked in 2002 and 2009 and drug-related deaths have been on the increase. Yet research has reported a limited number of available harm-reduction programs. This study aimed to estimate the size of high-risk drug using populations in Lithuania and to apply these estimates in assessing the coverage of opioid substitution treatment (OST) and needle and syringe programs (NSP). METHODS: We used indirect prevalence estimation methods (HIV and Mortality Multiplier, Capture-Recapture, Truncated Poisson and the Multivariate Indicator Method) to obtain annual prevalence estimates of the population of high-risk opioid users (HROU) and of people who inject drugs (PWID) in Lithuania in 2015/2016. We computed the coverage of OST (the annual percentage of HROU in these programs) and NSP (the number of provided syringes per PWID per year), using the prevalence estimates and the data from drug services. RESULTS: There were between 4854 and 12,444 HROU and between 8371 and 10,474 PWID in Lithuania in 2015/2016. In addition, we obtained a preliminary estimate of 4742-7000 high-risk amphetamine users. This constitutes around 2.5-6.5 HROU and 4.4-5.3 PWID per 1000 inhabitants aged 15-64. On average, 9.9-25.5% of HROUs were in OST and an average PWID in Lithuania obtained 19-29 syringes via NSPs during the study period. CONCLUSIONS: While the current prevalence of high-risk drug use in Lithuania is comparable to other European countries and for PWID, it is above the average; and the coverage of OST and NSP services in this population is markedly lower than in most countries of the European Union and warrants further investment.

Republic of Georgia estimates for prevalence of drug use: Randomized response techniques suggest under-estimation.

BACKGROUND: Validity of responses in surveys is an important research concern, especially in emerging market economies where surveys in the general population are a novelty, and the level of social control is traditionally higher. The Randomized Response Technique (RRT) can be used as a check on response validity when the study aim is to estimate population prevalence of drug experiences and other socially sensitive and/or illegal behaviors. AIM: To apply RRT and to study potential under-reporting of drug use in a nation-scale, population-based general population survey of alcohol and other drug use. METHODS: For this first-ever household survey on addictive substances for the Country of Georgia, we used the multi-stage probability sampling of 18-to-64-year-old household residents of 111 urban and 49 rural areas. During the interviewer-administered assessments, RRT involved pairing of sensitive and non-sensitive questions about drug experiences. RESULTS: Based upon the standard household self-report survey estimate, an estimated 17.3% [95% confidence interval, CI: 15.5%, 19.1%] of Georgian household residents have tried cannabis. The corresponding RRT estimate was 29.9% [95% CI: 24.9%, 34.9%]. The RRT estimates for other drugs such as heroin also were larger than the standard self-report estimates. DISCUSSION AND CONCLUSIONS: We remain unsure about what is the "true" value for prevalence of using illegal psychotropic drugs in the Republic of Georgia study population. Our RRT results suggest that standard non-RRT approaches might produce 'under-estimates' or at best, highly conservative, lower-end estimates.

Qualitative research in Spanish cannabis social clubs: "The moment you enter the door, you are minimising the risks".

BACKGROUND: Cannabis social clubs (CSCs) in Spain are non-profit organisations that connect regular adult cannabis users. One of their functions is to supply cannabis to the closed circuit of members. The CSCs do not breach any international treaties. The aim of the paper is to present the findings of a qualitative study among Spanish CSCs in order to assess their potential for minimising the harm resulting from cannabis use (such as respiratory and mental health risks, the risk of dependence, and social risks). METHOD: A convenience sample of 11 CSCs was selected from four regions of Spain - the Basque country, Catalonia, the Balearic Islands, and Galicia. 94 respondents took part in 14 focus groups (FGs). The number of participants in a FG ranged from two to 12. A semi-structured interview guide and a structured questionnaire were used in the FG. FINDINGS: Members described a variety of risk minimising features of the CSCs: the availability of a quality product and mechanisms for its control, availability of different strains of cannabis and knowledge about their different psychoactive effects, increased control over personal cannabis use, informal information sharing and interaction, reduced stigma, and reduced criminal risks. CONCLUSIONS: The fact that the CSCs have no incentive to increase members' consumption means that they should be considered to be feasible spaces for the implementation of public health policies. Policy objectives could include a requirement that CSC members have control over the quality of cannabis, that different strains of cannabis are available together with information on their effects, that quantity of cannabis at intake is restricted and planned for each member, and that harm minimisation activities are both formally and informally implemented in the clubs.

[New psychoactive substances and their prevalence in the Czech Republic]. / Nové psychoaktivní látky a jejich výskyt v Ceské republice.

Recently, there is a global growing concern over the new (mainly synthetic) psychoactive substances, known as legal highs, research chemicals or bath salts. They are represented by various chemical groups imitating "old" illicit drugs with stimulant, euphoric, hallucinogenic or sedative effects. In the Czech Republic, the peak of their use and supply was observed at the beginning of 2011, when new psychoactive substances were available in smart shops known locally as Amsterdam shops - in that time mainly synthetic cathinones and also synthetic cannabinoids were present. After legislative change that placed tens of new substances under the control of criminal law in April 2011, new psychoactive substances are available at Internet and their use is (after short and media driven boom in early 2011) rather limited and decreasing. Though, the use of new synthetic stimulants was recently reported locally among problem (injecting) drug users; new very potent synthetic opioids represent potential threat of further expansion in this users subgroup.

"Should I Buy or Should I Grow?" How drug policy institutions and drug market transaction costs shape the decision to self-supply with cannabis in the Netherlands and the Czech Republic.

BACKGROUND: This paper uses the framework of institutional economics to assess the impact of formal and informal institutions that influence the transaction costs on the cannabis market, and users' decisions to self-supply in the Czech Republic and the Netherlands, two countries with seemingly identical policies towards cannabis cultivation. METHODS: A comparative analysis was conducted using secondary qualitative and quantitative data in four areas that were identified as relevant to the decision to cultivate cannabis: (i) the rules of the game - cannabis cultivation policy; (ii) "playing the game" - implementation of cannabis cultivation policy, (iii) informal institutions - cannabis cultivation culture, and (iv) the transaction costs of the cannabis market - availability, quality, and relative cannabis prices adjusted by purchasing power parity. RESULTS: Although the two policies are similar, their implementation differs substantially. In the Czech Republic, law enforcement has focused almost exclusively on large-scale cultivation. This has resulted in a competitive small-scale cultivation market, built upon a history of cannabis self-supply, which is pushing cannabis prices down. In the Netherlands, the costs of establishing one's own self-supply have historically outweighed the costs associated with buying in coffee shops. Additionally, law enforcement has recently pushed small-scale growers away from the market, and a large-scale cannabis supply, partly controlled by organised criminal groups, has been established that is driving prices up. The Czech cannabis prices have become relatively lower than the Dutch prices only recently, and the decision to buy on the market or to self-supply will be further shaped by the transactions costs on both markets, by policy implementation and by the local culture. CONCLUSIONS: The ability to learn from the impacts of cannabis cultivation policies conducted within the framework of UN drug treaties is particularly important at a time when increasing numbers of countries are seeking more radical reforms of their cannabis policy.

Post-Soviet Central Asia: a summary of the drug situation.

BACKGROUND: The paper aims to provide a snapshot of the drug situation in Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan using the EU methodology of "harmonised indicators of drug epidemiology." METHODS: Most of the data reported here were gathered and analysed within the framework of the EU-funded CADAP project in 2012. Together with members of CADAP national teams, we conducted extraction from the databases of national institutions in the field of (public) health and law enforcement, issued formal requests for the provision of specific information to national governmental authorities, and obtained national grey literature in Russian. In specific cases, we leaned on the expert opinions of the national experts, gathered by means of simple online questionnaires or focus group. In the rather scarce cases where peer-reviewed sources on the specific topics exist, it is used for comparisons and discussion. RESULTS: All the post-Soviet Central Asian countries lack information on drug use in the general population. School surveys are relatively well developed in Kazakhstan, and Kyrgyzstan benefited from an international survey project on health in schools organised by private donors in 2009. For Tajikistan and Uzbekistan, the most recent available data on drug use in the school population are from 2006 and as such are of little relevance. Problem drug use is widespread in Central Asia and estimates of its prevalence are available for all four countries. All the post-Soviet Central Asian countries use a rather outdated system of narcological registers as the only source of data on drug users who are treated (and those investigated by the police), which was inherited from Soviet times. The availability of treatment is very low in all the countries reported on here except Kyrgyzstan; opioid substitution treatment (OST) was introduced first in Kyrgyzstan; Kazakhstan and Tajikistan are piloting their OST programmes but the coverage is extremely low, and in Uzbekistan the OST pilot programme has been abolished. HIV and hepatitis C virus (HCV) infections are concentrated in injecting drug users (IDUs) in Central Asia, with the situation in Kazakhstan having stabilised; HIV is on the increase among Kyrgyz IDUs. The sharp decrease in HIV and VHC seroprevalence among IDUs in Uzbekistan and Tajikistan still awaits an explanation. The system for monitoring of fatal drug overdoses needs substantial improvement in all the countries reported on here. Overall mortality studies of drug users registered in the narcological registers were performed in Uzbekistan, Kazakhstan, and Tajikistan; the highest excess mortality among registered drug users was found in Uzbekistan, and in all three countries, it was substantially higher for women than men. The seizures of illegal drugs are by far the highest in Kazakhstan; however, wild-growing cannabis represents 90% of these seizures. Uzbekistan was the country with the highest number of drug arrests. In Kazakhstan, after the decriminalisation of drug use in 2011, the number of reported drug-related offences dropped to below 50% of the figure for the previous year. CONCLUSION: The drug situation monitoring system in the four post-Soviet countries of Central Asia still needs substantial improvement. However, in its current state it is already able to generate evidence that is useful for the planning of effective national and regional drug policies, which would be of the utmost importance in the forthcoming years of the withdrawal of the International Security Assistance Force from Afghanistan.

Mortality of registered drug users in Central Asia.

BACKGROUND: Within the fifth phase of the Central Asia Drug Action Programme (CADAP) covering five post-Soviet Central Asian countries, an analysis of the mortality of drug users was performed. The results for Kazakhstan and Uzbekistan are presented in detail in this paper since results from Kyrgyzstan and Tajikistan are not considered valid and Turkmenistan did not provide data at all. METHODS: A system of registration of all users of illegal drugs known to the health and/or law enforcement authorities ("narcological registers") exists in Central Asian countries inherited from the system of Soviet "narcology". According to the legal norms, the death of a registered person should be recorded. We conducted indirect standardisation of crude mortality rates and computed the standardised mortality ratio (SMR) comparing observed number of deaths with expected number of deaths according to age and gender specific mortality rates in the general population of the same country. RESULTS: The results show excess mortality in registered drug users, particularly in registered females, in Uzbekistan (the latest available SMR for all those registered is 7.4; the SMR in females is 16.3) and Kazakhstan (4.0 and 12.9). The excess mortality is highest among young adults (18-34) in all the studies. CONCLUSION: Taking into account the limited quality and reliability of the data - first of all, the likely under-reporting of deaths in the narcological registers - the crude mortality rate among registered drug users is quite high when compared to EU countries. The SMR in total is comparably lower as a result of the high background mortality in the general population. This excess mortality is preventable and should be targeted by the national drug policies. Specifically, the programmes should target registered and unregistered female drug users.

Mortality of cohort of very young injecting drug users in Prague, 1996-2010.

AIM: To determine the mortality in a cohort of very young injecting drug users (IDUs), and the factors associated with it. DESIGN: A database linkage prospective (follow-up) cohort study. SETTING: A convenience sample of clients of 2 low-threshold facilities, 1 drug treatment clinic, and one special facility for children with severe behavioural disorders, who were all younger than 19 and older than 15, was interviewed one or more times in 1996-8 and asked to agree with their being interviewed again after 10 or more years. PARTICIPANTS: 151 (65 male, 86 female) IDUs recruited in October 1996 - December 1998. MEASUREMENT: Database linkage study compared unique identifiers (IDs) of the recruited subjects with the general register of deaths to determine the life status, and the causes of death of those deceased. Where necessary, we examined the death protocols directly. FINDINGS: Altogether, 8 deaths were registered between recruitment and 31st December 2008 (1,660 person-years). All the deceased were male, and all their deaths were "unnatural"--that is, caused by drug overdose or accident. This translates into the crude mortality rates for the whole cohort being 4.8 deaths per 1,000 person-years (PY), and into a specific mortality ratio in the males SMR=14.4 with the peak at the age of 15-20 (SMR=60.1), declining to SMR=8.2 at the age of 25-30. Except gender, we found no "predictors of death" in this high-risk cohort. CONCLUSION: The overall mortality in the cohort was substantially higher than in the general population; in the male part of the cohort of young injecting drug users it was excessively high in the first three years after recruitment, and caused by external causes exclusively; the mortality in the female sub-cohort was zero, i.e. lower than in the general population of the same age range. Our findings suggest a need to develop targeted prevention of overdoses and other unnatural deaths in young male drug injectors.

Hepatitis C in HIV-infected individuals: cure and control, right now.

For persons living with HIV, hepatitis C is a major public health problem that must be controlled and could be eliminated. The challenge arises because the hepatitis C virus (HCV) is prevalent among HIV-infected persons in most parts of the world, because HIV worsens all HCV outcomes, and because HCV may add additional individual economic and psychosocial complications to HIV disease. Despite the major benefits of antiretroviral therapy on HIV outcomes, antiretroviral therapy is not sufficient to halt the complications of HCV. Nonetheless, HCV can be controlled at all stages, including prevention of infection and cure. Thus, HCV is an eradicable disease. There are significant inequalities worldwide in HCV control that could markedly constrain the impact of these measures.

Use of gelatine capsules for application of methamphetamine: a new harm reduction approach.

BACKGROUND: In order to reduce injecting drug use, low-threshold facilities in the Czech Republic have started to distribute empty gelatine capsules as an oral alternative of drug application for those injecting methamphetamine. This report reviews implementation of this intervention and its possible benefits and limitations. METHODS: Between December 2008 and January 2009, 109 low-threshold facilities were asked to complete a questionnaire about the capsule programmes. Two focus groups were conducted, one with professionals involved in distribution and one with peer outreach workers who were interviewed on their experience of using the capsules. RESULTS: A total of 50 facilities (46%) responded to the questionnaire; 16 (32%) distributed the capsules regularly and 19 (38%) were planning to introduce this practice. The main target groups were injecting users of methamphetamine whose veins had been damaged, and methamphetamine users wishing to reduce injecting. The advantages of capsules, as perceived by service staff and peer outreach workers, were their easy use and the satisfactory effect of the oral application; health risks related to the oral use of methamphetamine were considered drawbacks. CONCLUSION: Capsule distribution is a promising harm reduction approach for injectors of methamphetamine or other stimulants; nonetheless its benefits and limitations should be further analysed in an in-depth longitudinal study.

[Ethanol and other psychoactive substances in fatal road traffic accidents in the Czech Republic in 2008]. / Výskyt etanolu a dalsích drog u smrtelných dopravních nehod v Ceské republice v roce 2008.

BACKGROUND: To map the recent prevalence of alcohol and other psychoactive substances in deceased victims of traffic accidents in the Czech Republic. MATERIAL AND METHODS: The studied sample consisted of individuals autopsied in the departments of forensic medicine who died during traffic accidents in 2008 and were toxicologically tested for one or more of the following substances: ethanol, volatile substances, cannabis, opiates, stimulants, cocaine, benzodiazepines, and barbiturates. Case definition involved alcohol cases with blood alcohol concentration (BAC) 0.2 g/kg and higher; with cannabis, detections of active THC metabolites only were taken into account; from cases where volatile substances (solvents) were detected we included into the positive cases only those where substances were not produced post mortem or in some physiological or pathological statuses. RESULTS: The sample consisted of 1,040 persons deceased in traffic accidents, of whom 582 (56.0%) were toxicologically tested for one or more of the substances listed above. The sample has been divided into two subsamples--one of 778 (74.8%) active participants of road traffic accidents (pedestrians, bicyclists, and drivers) and other subsample consisting of 262 (25.4%) non-active participants. Ethanol was found in 38.3% of 381 tested and at least one of other psychoactive substances was found in 11.7% of 384 tested active participants--of those, stimulants (mostly methamphetamine) were found most frequently (6.5% of 337 tested), cannabis (5.9% of 203 tested) and benzodiazepines (3.9% of 363 tested active participants). Drivers were positive for ethanol in 29.2% cases, for one or more of other psychoactive substances except ethanol in 12.7% cases, most frequently for stimulants (9.2%) and cannabis (6.2%). Professional drivers were found negative for ethanol and other psychoactive substance except of one case of methamphetamine (6.7%). CONCLUSION: The study confirms high prevalence of alcohol and other psychoactive substances, especially stimulants (methamphetamine), cannabis and benzodiazepines, among deceased participants of road traffic accidents including drivers in the Czech Republic.

Why do the clients of Georgian needle exchange programmes inject buprenorphine?

AIM: The aim of the study was to understand the prevalence and patterns of the non-medical injecting use of buprenorphine among drug injectors in Georgia. METHOD: A self-administered questionnaire was distributed among injecting drug users enrolled in Georgian needle exchange programmes. The questions covered topics related to drug use career, patterns (frequency, history, dosage) and reasons for the use of buprenorphine. RESULTS: Pharmaceutical buprenorphine in the form of Subutex was the most commonly injected drug in terms of lifetime (95.5%) and last-month (75%) prevalence of use. 48% of those study participants who had injected Subutex at some point reported having used it to cope with withdrawal or to give up other opioids. 90.5% of Subutex injectors used 1-2 mg as a single dose, and the mean frequency of its injection was 6 times per month. 75% of Subutex injectors had used 3 or more types of illegal drugs during the last 30 days. CONCLUSION: While widely misused by Georgian drug injectors, Subutex is neither the principal nor the favourite drug, and it is rather used as self-treatment. The authors consider the introduction of buprenorphine maintenance treatment to be a promising effective measure to decrease its non-medical and illegal use.

Mortality among amphetamine users: a systematic review of cohort studies.

AIMS: To report the results of a comprehensive literature search of studies of mortality among people who use amphetamines. DESIGN AND SETTING: Three electronic databases were searched (EMBASE, Medline and PsycINFO) and "grey" literature was located. Shortlists of papers were circulated to experts to ascertain whether any important papers had been missed. Papers were hand-searched to retrieve any additional relevant articles. MEASUREMENTS: Studies meeting inclusion criteria were prospective cohort studies examining mortality risk among dependent and problematic amphetamine users. Crude mortality rates (CMR/100PY) and standardised mortality ratios (SMRs) were the primary outcome measures considered. Data on overall mortality, and rates for specific causes of death, were of interest. FINDINGS: 2187 articles and 9 grey literature sources were obtained. After thorough review, 72 articles were identified as reporting on amphetamine-related mortality, 7 provided data from cohort studies of users. An additional study of Swedish military conscripts was identified by the authors during correspondence with other researchers. The geographic spread of cohorts was restricted to high income countries with the exception of one Thai study; reporting of standard parameters in mortality studies was often sparse. The estimated CMRs ranged from 0 in Australia to 2.95 (1.46-4.59) in Thailand. The Czech cohort reported the only SMR: 6.22 overall, males: 5.87, females: 7.84. CONCLUSIONS: Given the widespread use of amphetamines, the known non-fatal adverse effects of use and the mortality rates reported here, cohort studies investigating the morbidity and mortality associated with such drug use should be a research priority.

Drugs and fatal traffic accidents in the Czech Republic.

INTRODUCTION: The aim of the study was to determine the prevalence of psychotropic drug use in active participants in traffic accidents who died during the accident or shortly after it due to injuries resulting from the accident. METHODS: A special mortality register containing data of all forensic autopsies was analysed. The studied sample consisted of persons who died during traffic accidents and were active participants in those ones (pedestrians, cyclists, or drivers), and were toxicologically tested during the forensic examination. RESULTS: The sample consisted of 1,213 cases, 1,039 (85.7%) males and 174 (14.3%) females who died in 2003-2005. Ethanol was found in 34.7% of cases, however a significant declining trend over the years was noted. The proportion of positive detections for any psychotropic drug other than alcohol was 7.2%; benzodiazepines were found most frequently (3.6%), followed by cannabis (2.2%), and stimulants (1.7% of the sample). Positive findings of ethanol were significantly more common among males, whereas positive benzodiazepine tests were more frequent in females. Positive cases were significantly younger than negative ones for ethanol, volatile substances, stimulants, and cannabis; in cases of positive medicaments tests, the positive cases were significantly older than the negatives.

Hepatitis C virus infection among injecting drug users in the Czech Republic -- prevalence and associated factors.

AIM: To determine the prevalence of, and factors associated with, hepatitis C virus (HCV) infection in the population of Czech injecting drug users (IDUs). DESIGN: Multicentric cross-sectional study. SETTING: A convenience sample of injecting drug users was recruited using the snowball sampling method. PARTICIPANTS: Sample of 760 IDUs from 9 different Czech regions. MEASUREMENT: We used one-drop instant blood tests to determine the anti-HCV antibodies status; a structured questionnaire was completed during the interview with the researcher. We calculated the ratio of positive findings and performed univariate analyses of correlations between predictors and independent variables. Finally, we created a logistic regression model that controlled for age, region of residence, reported sharing of injection paraphernalia, and length of injection drug use and for the interaction between length of injection use and imprisonment in order to assess the predictive value of imprisonment in an individual's history. FINDINGS: 226 participants (29.74% of the tested sample) were found to be anti-HCV positive. After adjusting for the sensitivity of the test, the 'true proportion' was 34.97% (95% CI: 31.56-38.35). Many correlated independent variables were found in the univariate analyses. In our logistic regression model, we have found that imprisonment increases the odds of being anti-HCV positive by a factor of 4.3. CONCLUSION: Anti-HCV seroprevalence remains relatively low in the Czech IDUs population compared to similar populations in the developed countries. Regional differences exist in anti-HCV prevalence within the Czech Republic. The strong association of anti-HCV prevalence with imprisonment history when controlled for other potentially clinically important factors suggests the need for more effective preventive measures in Czech prisons.