Divergent Patterns of Amphetamine Use in the City and Rural Areas in Northwest Poland Sobeyko J (1), Leszczyszyn-Pynka M (2), Parczewski M (2), Burris S (3)(6), Lazzarini Z (4)(6), Case P (5), Chintalova-Dallas R (4).

(1) Infectious Disease Prevention Association for Western Pomerania, Poland (2) Department of Infectious Diseases & Hepatology Pomeranian Medical University, Szczecin, (3) Temple University Law School, (4) University of Connecticut Health Center, (5) Fenway Community Health Center, (6) Center for Law and the Public’s Health at Georgetown and Johns Hopkins Universities

Background: Amphetamines are the second most commonly used drugs in Northwest Poland (after marijuana). Policy research conducted in the region points to important differences between the Polish city of Szczecin and regional towns and rural areas (RRAs) that surround it in drugs used, modes of administration, and user characteristics. These differences raise concern that bloodborne diseases, including HIV and Hep C could spread rapidly in rural areas.

Methods: Rapid Policy Assessment and Response (RPAR) is an intervention that mobilizes local knowledge and capacity to fight HIV/AIDS among sex workers, injection drug users, and members of other marginalized populations at the city level. In RPAR, a research team from a site city works with a Community Action Board (CAB) to collect three kinds of data: laws and written policies relevant to health risks in the target populations; existing data on the epidemiological situation and the operation of the criminal justice system; and qualitative interviews with police, judges, prosecutors, drug users, sex workers and others who can describe how the laws are put into practice. The data collection and interpretation are guided by the CAB, which develops an action plan and final report. The Szczecin RPAR was begun in January, 2005 and concluded with a final report in March, 2006. The CAB included representatives of law enforcement (the police, judiciary, prisons), both public and private drug treatment providers, health care (physicians, nurses) and social welfare agencies (Family Support office). Existing laws and formal policies in ten domains relevant to drug policy and health (including harm reduction, drug treatment and prevention) were collected. To determine how these laws were being put into practice, three focus groups were conducted, and the team interviewed 24 people in law enforcement, health care and social services, as well as 14 IDUs.

Results: See Table:

Discussion: : Data from this project suggest that there may be differences in drug use patterns, characteristics of users, knowledge of risks, and availability of prevention and treatment services between the Polish city of Szczecin and the surrounding region and rural area that could be increasing the risk of transmission of HIV and other bloodborne infections. We found evidence of use of amphetamines, specifically injected amphetamines, in the countryside that was unknown to local authorities. Moreover, the local users interviewed in the RRA displayed less knowledge of the risk of injecting amphetamines, more barriers to access to sterile syringes, and more unsafe injection practices, than did users interviewed in Szczecin. This is unsurprising given the reported lack of outreach to drug users, HIV education, operation of a SEP, or other harm reduction programs, or even (non-alcohol) drug treatment programs in the RRA. The data, although limited, on lower age of initiation of use of amphetamines in the RRA are also worrisome. They suggest that young teens and even pre-teens may be at significantly increased risk of bloodborne diseases in an environment that is currently poorly equipped to address their needs. These data, based on a rapid policy assessment model (RPAR), indicate a need for more comprehensive assessment of the behaviors of rural drug users, the barriers to knowledge and safe injection practices, and the needs of local authorities to address the problem. It is hoped that initiation of one or more local RPARs in the area around Szczecin will be the next step in providing this information.

This research was supported by NIDA/NIH Grant # 5 R01 DA17002-02 PI: LAZZARINI, ZITA . The findings and conclusions expressed are those of the authors and not necessarily of NIH, NIDA, or the US Government.

The development of RPAR was supported by the International Harm Reduction Development Program of the Open Society Institute in 2001-2002.

Conclusions: 1. Data on use of amphetamines, rapid progression to injection as a mode of administration, and users’ lack of knowledge of risks, suggests possible that drug use in rural areas is different from that in the city of Szczecin.2. Significant barriers exist to safe injection practices, in the form of reduced access to sterile syringes (through SEPs or sale in pharmacies).3. These same factors point to increased risk of transmission of HIV and other bloodborne diseases among drug users in RRAs.4. Local officials may be unaware of the scope of injection practices and related risks.5. Local drug use prevention and treatment programs are not designed to address needs of IDUs.6. Use of the RPAR assessment and response model may help localities respond to changing drug use situation.

The limitations of our methodology:Our findings are based on interviews from purposively selected informants and by the information provided by our CAB, supported where possible by epidemiological statistics and secondary sources. The data must be viewed with appropriate caution. Given the experience of rural amphetamine use in other areas, however, and the potentially rapid spread of bloodborne disease among injectors, they should be taken seriously and followed up with more sustained research and intervention work.

Infectious Diseases Prevention Association for Western Pomerania

Region

Department of Infectious Diseases&

Hepatology Pomeranian Medical University,

Szczecin

IDUs unaware of HIV risk related to injecting amphetaminesIDUs reported three primary reasons for not using sterile equipment: 1) difficulty obtaining syringes, 2) belief that only kompot (homemade heroin) carries an HIV risk, and 3) belief that none of their network is infected. (IDUs, female age 26, male age 40 and male age 43)

IDUs aware of HIV risk, use sterile syringes“Everybody uses sterile needles and syringes. Too many of my friend got infected many years ago… If we had known it earlier. Now everybody knows. But we didn’t 10-15 years ago”. (IDU, female, 45)“I don’t know anybody who would share equipment now. Ten years ago it happened quite often ” (IDU, female, 48)

Awareness of HIV risk

IDUs only treated with alcoholics“National health service does not pay for treatment of drug users in here. We need to treat them together with alcoholics, in the same groups and try to get our money back. We like mixed dependencies as they are easier to get paid for.” (Therapist, RRA)

Methadone and other treatment availableIn Szczecin, 75 IDUs receive methadone. Nationwide, the 800 people on methadone in Poland is about 2% of opiate addicts who could qualify to treatment. (EMCDDA estimates)

Drug treatment

Local drug treatment personnel are not aware of the scale of the problem of injection drug use.“I know they take drugs. Everybody uses them here. But I don’t think they inject …, no, it’s not possible, I have never heard of it.”(Therapist in Rural Area)

Information widely distributed through “party programs” and magazines on safe injection practices, overdose prevention, legal advice for drug users. (confirmed by interviews with Harm Reduction Workers and 3 Police)

Awareness of problem of injected amphetamine use

IDUs in RRAs report that pharmacist are not willing to sell equipment and IDUs are reluctant to use pharmacies because of stigma of drug use. “You can buy equipment in a pharmacy but sometimes the seller says there are no small needles. It’s not a problem for us [old opiate users], but still it’s a problem for those young kids who cannot make injections.” (IDU, male, 43)“It’s a problem for those kids to inject using needle No. 9, they need [a No.] 2, they cannot get them so they share their old needles.”(IDU, male, 40)“they don’t want to go to pharmacy as they are afraid to be perceived as dug addicts. Though their parents and neighbors are all addicted to alcohol.” (IDU, female, 26)

Widely available, Syringes cost about 0.35 PLN each ($0.10 US).“There is no point in going to the syringe exchange because we can buy syringes in any pharmacy.” (IDU, female, 32)

Syringe Sale in Pharmacies

No SEPSEP with fewer clients every yearSyringe Exchange Program

Lack of alternative leisure activities, few job prospects “Nothing is free here - a swimming pool costs 10 PLN, a gram of amphetamines is 3-5 PLN.” (IDU, male, 43)“Kids have nothing to do after school”( IDU, male, 40) “They don’t believe they can live in other way than their parents – they only difference is that parents drink alcohol, kids use drugs”.(IDU, male, 43)

Mainly recreational, users come from higher social and financialclass (Police interviews)“When I have a business meeting I need to take something – it really helps. Not much, but enough to feel and work better.”(IDU, male, 24)

“I work in the bank. I need to be so efficient that I started to take amphetamine after a half a year of working there. My friend advised me to do it”(IDU, female, 32)

Primary reasons for amphetamine use

Drug users report that age of initiation of amphetamine use is younger in RRAs than in the city. One user estimated that rural users begin as young as 9-11 years old, as opposed to 16-17 in the cities.“…my neighbor … all his children use drugs – even the youngest [9 years old]– he started a year ago – with inhaling amphetamine. But then, his brothers showed him how to inject”. (IDU, male, age 40)

“Most of my teenage neighbors have already tried drugs, some of them are addicted” (IDU, female, age_26)

Average age of drug initiation – secondary school – age of 16 (survey ESPAD, nationwide survey)

Age of initiation of amphetamine use

Injection most prevalent“everybody starts with inhaling amphetamine. But it takes 4-6 months to switch from inhaling to injection” on why “it’s a pressure environment- if you don’t inject, you are a coward, moreover it’s a money issue – injecting amphetamine is more efficient.” (IDU, male, age 40)

Inhaled or injested common

“I inject very rarely– only when I need a strong kick. Usually I use amphetamine in clubs (orally)…” (IDU, male, 24)

Route of amphetamine use

“The further you are from Szczecin, the cheaper the drugs: 30-35 PLN [US $9.50-$11.00/gram] in Szczecin, 20 PLN [$6.33/gram] in ST (city of ~50,000 in Szczecin region), 12 PLN [$3.80/gram] in CH (city of ~50,000 in Szczecin region). The quality is linked not so much with the price as with who you know and whom are you known to …” (IDU, female, 26; IDU, male, 29; IDU, male, 43)

More expensiveCost of amphetamines

Widely available“there are no problems to buy amphetamine, even if you are a stranger in the town. The only difference is that strangers have higher prices,…” (IDU, female, age 26)

Widely availableAvailability of amphetamines

RRAs - Key Findings from qualitative interviewsSzczecin - Key Findings from qualitative interviews

IDUs unaware of HIV risk related to injecting amphetaminesIDUs reported three primary reasons for not using sterile equipment: 1) difficulty obtaining syringes, 2) belief that only kompot (homemade heroin) carries an HIV risk, and 3) belief that none of their network is infected. (IDUs, female age 26, male age 40 and male age 43)

IDUs aware of HIV risk, use sterile syringes“Everybody uses sterile needles and syringes. Too many of my friend got infected many years ago… If we had known it earlier. Now everybody knows. But we didn’t 10-15 years ago”. (IDU, female, 45)“I don’t know anybody who would share equipment now. Ten years ago it happened quite often ” (IDU, female, 48)

Awareness of HIV risk

IDUs only treated with alcoholics“National health service does not pay for treatment of drug users in here. We need to treat them together with alcoholics, in the same groups and try to get our money back. We like mixed dependencies as they are easier to get paid for.” (Therapist, RRA)

Methadone and other treatment availableIn Szczecin, 75 IDUs receive methadone. Nationwide, the 800 people on methadone in Poland is about 2% of opiate addicts who could qualify to treatment. (EMCDDA estimates)

Drug treatment

Local drug treatment personnel are not aware of the scale of the problem of injection drug use.“I know they take drugs. Everybody uses them here. But I don’t think they inject …, no, it’s not possible, I have never heard of it.”(Therapist in Rural Area)

Information widely distributed through “party programs” and magazines on safe injection practices, overdose prevention, legal advice for drug users. (confirmed by interviews with Harm Reduction Workers and 3 Police)

Awareness of problem of injected amphetamine use

IDUs in RRAs report that pharmacist are not willing to sell equipment and IDUs are reluctant to use pharmacies because of stigma of drug use. “You can buy equipment in a pharmacy but sometimes the seller says there are no small needles. It’s not a problem for us [old opiate users], but still it’s a problem for those young kids who cannot make injections.” (IDU, male, 43)“It’s a problem for those kids to inject using needle No. 9, they need [a No.] 2, they cannot get them so they share their old needles.”(IDU, male, 40)“they don’t want to go to pharmacy as they are afraid to be perceived as dug addicts. Though their parents and neighbors are all addicted to alcohol.” (IDU, female, 26)

Widely available, Syringes cost about 0.35 PLN each ($0.10 US).“There is no point in going to the syringe exchange because we can buy syringes in any pharmacy.” (IDU, female, 32)

Syringe Sale in Pharmacies

No SEPSEP with fewer clients every yearSyringe Exchange Program

Lack of alternative leisure activities, few job prospects “Nothing is free here - a swimming pool costs 10 PLN, a gram of amphetamines is 3-5 PLN.” (IDU, male, 43)“Kids have nothing to do after school”( IDU, male, 40) “They don’t believe they can live in other way than their parents – they only difference is that parents drink alcohol, kids use drugs”.(IDU, male, 43)

Mainly recreational, users come from higher social and financialclass (Police interviews)“When I have a business meeting I need to take something – it really helps. Not much, but enough to feel and work better.”(IDU, male, 24)

“I work in the bank. I need to be so efficient that I started to take amphetamine after a half a year of working there. My friend advised me to do it”(IDU, female, 32)

Primary reasons for amphetamine use

Drug users report that age of initiation of amphetamine use is younger in RRAs than in the city. One user estimated that rural users begin as young as 9-11 years old, as opposed to 16-17 in the cities.“…my neighbor … all his children use drugs – even the youngest [9 years old]– he started a year ago – with inhaling amphetamine. But then, his brothers showed him how to inject”. (IDU, male, age 40)

“Most of my teenage neighbors have already tried drugs, some of them are addicted” (IDU, female, age_26)

Average age of drug initiation – secondary school – age of 16 (survey ESPAD, nationwide survey)

Age of initiation of amphetamine use

Injection most prevalent“everybody starts with inhaling amphetamine. But it takes 4-6 months to switch from inhaling to injection” on why “it’s a pressure environment- if you don’t inject, you are a coward, moreover it’s a money issue – injecting amphetamine is more efficient.” (IDU, male, age 40)

Inhaled or injested common

“I inject very rarely– only when I need a strong kick. Usually I use amphetamine in clubs (orally)…” (IDU, male, 24)

Route of amphetamine use

“The further you are from Szczecin, the cheaper the drugs: 30-35 PLN [US $9.50-$11.00/gram] in Szczecin, 20 PLN [$6.33/gram] in ST (city of ~50,000 in Szczecin region), 12 PLN [$3.80/gram] in CH (city of ~50,000 in Szczecin region). The quality is linked not so much with the price as with who you know and whom are you known to …” (IDU, female, 26; IDU, male, 29; IDU, male, 43)

More expensiveCost of amphetamines

Widely available“there are no problems to buy amphetamine, even if you are a stranger in the town. The only difference is that strangers have higher prices,…” (IDU, female, age 26)

Widely availableAvailability of amphetamines

RRAs - Key Findings from qualitative interviewsSzczecin - Key Findings from qualitative interviews

Patterns of Drug Use, Characteristics of Users and Local Programs