Emerging Risks Due to New Injecting Patterns in Hungary During Austerity Times

Abstract

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.

Keywords :

• Injecting drugs use
• new psychoactive substances
• synthetic cathinones
• heroin shortage
• hepatitis C
• syringe sharing
• risk behaviors
• syringe-exchange program
• harm reduction
• economic recession

THE AUTHORS

Anna Tarján, MSc, is a sociologist at the Hungarian Reitox National Focal Point in the network of the EMCDDA. Her research activities mainly focus on drug-related infectious diseases, harm reduction in the PWID population, and drug use and related interventions in the prison setting. She is a PhD student at the Faculty of Health Sciences, Semmelweis University, Budapest, Hungary conducting research on risk behaviors and other correlates of HCV infection among Hungarian PWID. She also volunteers at a syringe exchange program in Budapest.

Mária Dudás, MD, MSc, is an epidemiologist at the National Centre for Epidemiology, in Hungary. Her main area of interest is infectious disease epidemiology, in particular sexually transmitted infections, HIV/AIDS, and other drug-related infectious diseases.

V. Anna Gyarmathy, PhD, MSc completed her PhD in clinical psychology with a concentration in behavioral sciences at Semmelweis University in Budapest, Hungary and her postdoctoral training at the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health. She holds an adjunct faculty position at the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health in Baltimore, MD, USA. Her research has concentrated on social and risk networks, and the epidemiology and prevention of HIV/AIDS and hepatitis infections among disadvantaged and at-risk populations (such as injecting and noninjecting drug users) in the European Union, United States, and Russia.

Erzsébet Rusvai, PhD, MD, is the head of the Serology Laboratory for Hepatitis Viruses at the National Centre for Epidemiology in Hungary, Budapest. Her main area of interest is hepatitis viruses.

Bálint Tresó, MSc, is a biologist at the National Centre for Epidemiology, National Reference Laboratory of Hepatitis viruses, in Budapest, Hungary, and a doctoral student at the Eötvös Loránd University, Doctorate School in Biology, Budapest, Hungary. His main areas of interest are Hepatitis viruses and viral infections in high-risk populations.

Ágnes Csohán, MD, is a chief epidemiologist at the National Centre for Epidemiology, Budapest, Hungary. Her main areas of interest are infectious disease surveillance, prevention and control of blood-borne and vaccine-preventable infections.

GLOSSARY

• Risk environment: “A risk environment framework envisages drug use-associated harms as a product of the social situations and environments in which individuals participate. It shifts the responsibility for drug harm, and the focus of harm reducing actions, from individuals alone to include the social and political institutions which have a role in harm production” (Rhodes, 2009).

• PWID who currently inject: A person who injected drugs within 4 weeks prior to the survey.

• Harm reduction: Harm reduction is an approach, and ideology, which refers to policies or programs that focus directly on reducing the health-related, social and economic harm resulting from drug use, both to the individual and to the larger community. Harm reduction programs help to prevent HIV, viral hepatitis, overdoses and other conditions widespread among PWID and decreases drug use-related social and health problems or death.

• Syringe-exchange programs (SEP): Through SEPs it is possible that PWID obtain sterile injecting equipment (needles, syringes, filters, etc.) or exchange their already used ones to sterile ones for free. However, it does not only mean the distribution of sterile paraphernalia but the collection and safe disposition of the used ones in order to prevent the transmission of viral infections. In addition to exchanging needles/syringes, SEPs often distribute condoms, provide counseling, and a range of examinations and education about safer sexual behavior and safe injecting practices.

• New psychoactive substances (NPS): NPS are psychoactive substances, either in pure form or preparation, that are not controlled by international drug conventions, but which may pose a public health threat (e.g., synthetic cannabinoids; synthetic cathinones). In this context, the term “new” does not necessarily refer to new inventions but to substances that have newly become available in specific markets. They are often marketed as “legal highs.” In general, NPS is an umbrella term for unregulated (new) psychoactive substances or products intended to mimic the effects of controlled drugs (UNODC, 2013). In this study self-reported, street-name based mephedrone, MDPV, pentedrone, 4-MEC, methylone, 4-Fluoroamphetamine, PPMC, “designer drugs” were grouped as NPS.

• Synthetic cathinones: Synthetic cathinones encompass a wide group of substances that are synthetic derivatives of cathinone, which is naturally present in the Khat (Catha edulis) plant. They include mephedrone, pentedrone, methylone, MDPV, and 4-MEC. They mainly appear on the drug markets as powders and tablets (EMCDDA, 2014). They are claimed to have effects similar to those of cocaine, amphetamine, or MDMA (ecstasy), but little is known of their detailed pharmacology. Apart from cathinone, methcathinone, amfepramone, and pyrovalerone, cathinone derivatives are not under international control (EMCDDA, 2012b).

• The first widely used synthetic cathinone was mephedrone around 2007, causing an international alert by producing serious intoxications and deaths in various countries. After this compound had been scheduled in many countries, another synthetic cathinone, 3,4-methylenedioxypyrovalerone (MDPV) became popular among drug users, also causing seriously health consequences. Currently, MDPV is controlled in most European countries, but the emergence of new synthetic cathinones –such as pentedrone –is continuous (Szily & Bitter, 2013).

• In Hungary, mephedrone was scheduled as an illicit drug in January 2011, while 4-methylethcathinone (4-MEC), 3,4-methylenedioxypyrovalerone (MDPV), and methylone in January 2012. In April 2012 pentedrone was placed on a list of temporary scheduled substances which only restrict trafficking while risk assessment is being conducted (HNFP, 2012).

• Syringe sharing: Lending and/or borrowing as well as otherwise using a needle/syringe already used by someone else, even if cleaned (EMCDDA, 2013c).

• Injecting equipment sharing: Lending and/or borrowing as well as otherwise using any injecting equipment already used by someone else, even if cleaned –for example, needle/syringe, water, cotton/filter, cooker, spoon, acidifier, etc. (EMCDDA, 2013c).

• Drug market: In this paper, drug market refers to licit and illicit drug supply and availability at wholesale and retail level defined on the basis of international and domestic intelligence and seizure data.

Notes

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 man-made, 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.

² These target levels are based upon studies in developed-country settings and mathematical modelling investigating the levels of syringe distribution and its impact on HIV transmission. It is to be noted that the levels required for the prevention of HCV are likely to be much higher than those proposed here.” (WHO, et al., 2013).

³ The reader is referred to Hills's criteria for causation which were developed in order to help assist researchers and clinicians determine if risk factors were causes of a particular disease or outcomes or merely associated. (Hill, 1965).

⁴ As a comparison: While in 2011 63% of the samples came from SEPs, 2% from DTCs, 2% from OST, 33% from organisations providing both SEP and OST, in 2012 only 26% of the samples came from SEPs, a further 2% came from DTCs, 33% from OST, and 39% from organisations providing both SEP and OST. (HNFP, 2013).