NationalReport

The Former Yugoslav Republic of Macedonia

2014

 

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NNaattiioonnaall rreeppoorrtt oonn nnaarrccoottiicc ddrruuggss

 

This report has been produced with the support of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), within its European Union financed IPA project 2011/280-057

‘Preparation of IPA Beneficiaries for their participation with the EMCDDA’. The views expressed herein can in no way be taken to reflect the official opinion of the European Union. 

October 2014

 

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Preparedby:TatjanaPetrusevska,MBAfarm.spec.HeadofDepartmentforControlledSubstancesMinistryofHealthIncooperationwithrepresentativesof:AgencyforYouthandSportsCentresforPublicHealthCentresfortheTreatmentandHarmReductionofDrugAddictionClinicofToxicology,St.CyrilandMethodiusUniversity,SkopjeCustomsAuthorityDepartmentofPsychiatry,StCyrilandMethodiusUniversity,SkopjeInstituteforPublicHealthInstituteofEpidemiologyandBiostatistics,StCyrilandMethodiusUniversity,SkopjeInstituteofForensicMedicine,StCyrilandMethodiusUniversity,SkopjeMinistryofAgriculture,ForestryandWaterManagementMinistryofEducationandScienceMinistryofForeignAffairsMinistryofHealthMinistryofInternalAffairsMinistryofLabourandSocialAffairsMinistryofLocalGovernmentandPlanningNon‐governmentalorganisationHealthyOptionsProjectSkopje(HOPS)Non‐governmentalorganisationsactiveinharmreductioninrelationtodrugusePrivatehealthorganisationswithapsychiatryspecialty:HelioMedica,DrGramov,EvromedikaPsychiatricHospitalSkopjeInter‐ministerialCommissionforNarcoticDrugs

 

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ContentsAbbreviations ............................................................................................................................................ 6 

1. DRUG POLICY: legislation and strategies .................................................................................................. 7 

1.1. Legal framework ................................................................................................................................ 7 

1.1.1.  Criminal Code Articles 215 and 216 ...................................................................................... 8 

1.1.2 Criminal Procedure Law ............................................................................................................. 10 

1.1.3. Law for Combating Narcotics and Psychotropic Substances .................................................... 10 

1.1.4. Adoption of amendments to the List of Controlled Substances ............................................... 10 

1.2. National Strategy and Action Plan: evaluation and coordination.................................................... 11 

1.2.1. National Drugs Strategy (2006–12) and Action Plan ................................................................ 11 

1.2.2. Implementation of the Strategy and Action Plan ..................................................................... 12 

1.2.3. Evaluation of the Strategy and Action Plan .............................................................................. 13 

1.3.  Coordination mechanism ............................................................................................................ 25 

1.3.1. The Inter‐ministerial Commission for Narcotic Drugs .............................................................. 25 

1.3.2. National focal point (NFP) ......................................................................................................... 27 

1.4. The process of adoption of the new National Drugs Strategy (2014–20) ....................................... 28 

1.5. Economic issues ............................................................................................................................... 30 

1.5.1. The Healthcare Programme for People with Addictions .......................................................... 30 

2.  DRUG USE IN THE GENERAL POPULATION SURVEY (GPS) .................................................................. 32 

2.1. Drug use in the school and youth population .................................................................................. 32 

2.1.1. The European School Survey Project on Alcohol and Other Drugs .......................................... 32 

2.1.2. Health Behaviour in School‐aged Children ............................................................................... 33 

2.1.3. Research conducted on negative childhood experiences: a representative sample of students from high schools and colleges  .......................................................................................................... 35 

3. PREVENTION ........................................................................................................................................... 36 

3.1. Universal prevention ........................................................................................................................ 36 

3.1.1. School ........................................................................................................................................ 36 

3.1.2. Community ................................................................................................................................ 39 

3.2. Selective prevention in at‐risk groups and settings ......................................................................... 40 

3.2.1. SOS Drugs Helpline .................................................................................................................... 40 

3.3. Indicated prevention ........................................................................................................................ 40 

 

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4. PROBLEM DRUG USE ............................................................................................................................... 42 

4.1. Improving the quality of drug dependence treatment programmes in Skopje  .............................. 42 

5. DRUG‐RELATED TREATMENT: DEMAND AND AVAILABILITY .................................................................. 46 

5.1. Introduction: the general concept of collecting treatment data at the European level ................. 46 

5.2. Strategy/policy ................................................................................................................................. 48 

5.2.1. Guidelines on Providing Healthcare when Administering Methadone for Opiate Dependence Treatment  .......................................................................................................................................... 49 

5.2.2. Guideline on Providing Healthcare when Administering Methadone for Opiate Dependence Treatment ........................................................................................................................................... 49 

5.3. The treatment system ...................................................................................................................... 49 

5.3.1. The characteristics of treated clients ........................................................................................ 50 

5.3.2. Therapeutic communities ......................................................................................................... 57 

5.3.3. Rehabilitation services .............................................................................................................. 57 

6. HEALTH CORRELATES AND CONSEQUENCES .......................................................................................... 58 

6.1. Report on the current state of play of the 2003 Council Recommendation on the prevention and reduction of health‐related harm associated with drug dependence, in the EU and candidate countries, Country Profiles, 2013 ........................................................................................................... 58 

6.2. Policies relating to health correlates and consequences................................................................. 63 

6.2.1. National Strategy for HIV/AIDS 2012–16  ................................................................................. 64 

6.2.2. Strategy on the Healthcare of the Prison Population (2012–14) and Action Plan ................... 65 

6.2.3. Interventions to prevent infectious diseases ............................................................................ 65 

6.2.4. Drug‐related deaths and emergencies ..................................................................................... 66 

6.2.5. Interventions to prevent and reduce drug‐related harm in recreational settings ................... 70 

6.2.6. Quality assurance in harm reduction ........................................................................................ 71 

6.3. Needle and syringe exchange programmes ..................................................................................... 72 

6.4. Voluntary counselling and HIV testing ............................................................................................. 74 

6.5. Information on problem drug users from non‐treatment sources .................................................. 77 

6.6. Harm reduction programmes (sharing needles, OST, counselling centres and support) in Skopje in 2012 ........................................................................................................................................................ 78 

7. SOCIAL CORRELATES AND CONSEQUENCES ........................................................................................... 80 

7.1. Treatment of drug users in prison ................................................................................................... 80 

8. RESPONSES TO SOCIAL CORRELATES AND CONSEQUENCES .................................................................. 82 

8.1. Social reintegration of drug addicts ................................................................................................. 82 

 

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8.2. Responses to social correlates and consequences in the new National Drugs Strategy ................. 83 

9. DRUG MARKETS ...................................................................................................................................... 84 

9.1. The general situation regarding drug supply activities .................................................................... 84 

9.1.1. The domestic production of drugs ............................................................................................ 85 

9.2. Narcotics prices ................................................................................................................................ 86 

9.3. Narcotics seizures ............................................................................................................................ 87 

9.3.1 Narcotics seizures at border crossing points, 2013 ................................................................... 88 

 

 

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Abbreviations AIDS acquiredimmunedeficiencysyndromeBZD benzodiazepinesCBM communitybasedmonitoringCRC citizenreportcardsDRD drug‐relateddeathDRID drug‐relatedinfectiousdiseaseEMCDDA EuropeanMonitoringCentreforDrugsandDrugAddictionEU EuropeanUnionGlobalFundGlobalFundtoFightAIDS,TuberculosisandMalariaHBV hepatitisBvirusHCV hepatitisCvirusHIV humanimmunodeficiencyvirusHOPS HealthOptionsProjectSkopjeIDU injectingdruguse,injectingdruguserIMCND Inter‐ministerialCommissionforNarcoticDrugs IPA InstrumentforPre‐AccessionAssistanceMKD MacedoniandenarsMMT methadonemaintenancetreatmentNFP nationalfocalpointNGO non‐governmentalorganisationNSP needleandsyringeexchangeprogrammeOST opioidsubstitutiontreatmentPDU problemdruguse,problemdrugusersPHI PublicHealthInstitutionReitox ReseauEuropeendInformationsurlesDroguesetlesToxicomanies

(Europeaninformationnetworkondrugsanddrugaddiction)TDI treatmentdemandindicatorUNODC UnitedNationsOfficeonDrugsandCrimeVCCT VoluntaryConfidentialCounsellingandTestingcentreVCT voluntarycounsellingandtestingWHO WorldHealthOrganization

 

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1.DRUGPOLICY:legislationandstrategies

1.1.Legalframework Drugs legislationhas ahighpriority in theFormerYugoslavRepublicofMacedonia.Thelegalframeworkisbeingcontinuouslyupdatedtoharmonisewithinternationalstandardsand conventions, includingpolitical directions from theUnitedNations, the principles oftheWorld Health Organization and European Union directives. In addition to the basiclegislation, the legal framework incorporates laws that amend specific areas. The mostimportantlawsintheareaofdrugsinclude:

x LawforProductionandTradeofNarcoticDrugs;x LawforPrecursors;x LawonInternalAffairsandbylaws;x PoliceActandregulations;x LawonBorderControlandbylaws;x LawonOffencesagainstPublicOrderandbylaws;x LawforStorageandProtectionofFlammableLiquids;x LawforInterception;x CriminalCode;x LawonManagementofConfiscatedProperty,PropertyBenefitsandItemsSeizedin

CriminalandMisdemeanourProcedure;x LawonProtectionofPersonalData;x LawonMisdemeanours;x LawonPreventionofCorruption;x LawofPublicProsecution;x TheCriminalProcedure;x LawonExecutionofSanctions;x LawonFreeLegalAid;x LawonSocialProtection;x CustomsLaw;x LawonCustomsTariff;x LawonCustomsAdministration;x LawonIntellectualPropertyRights;x LawonSocialProtection;x LawonHealthInsurance;x HealthcareLaw; x LawonNationalCriminalIntelligenceDatabase.

 

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TheFormerYugoslavRepublicofMacedoniahasratifiedthefollowingconventions:

x United Nations (UN) Single Convention on Narcotic Drugs (1961), ProtocolAmending the Single Convention on Narcotic Drugs (1972), UN Convention onPsychotropic Substances (1971), UN Convention Against Illicit Traffic in NarcoticDrugsandPsychotropicSubstances(1988);

x Council of Europe Convention on Laundering, Search, Seizure and Confiscation oftheProceedsfromCrime(1990)(signedandratified);

x CriminalLawConventiononCorruption(1998)(enteredintoforceon1July2002);x CivilLawConventiononCorruption(ratifiedon16February2002);x European Convention on Mutual Assistance in Criminal Matters (1957), with

AdditionalProtocoltotheConventionof1958(ratified28July1999);x Second Additional Protocol to the European Convention on Mutual Assistance in

CriminalMatters(ratified24June2003);x European Convention on Extradition (1957), with Additional Protocol to the

Convention (1957), and Second Additional Protocol to the Convention (1978)(ratified28July1999);

x Convention on the Transfer of SentencedPersonswithAdditional Protocol to theConvention(1977)(ratified28July1999andenteredintoforce1June2000);

x EuropeanConventionontheTransferofProceedingsonCriminalMatters(ratifiedin2004);

x EuropeanConventionontheSuppressionofTerrorism(ratifiedin2004);x UNConventionagainstTransnationalOrganizedCrime(signed14December2000,

inprocessofratification);x EuropeanConventiononCybercrime(ratifiedin2004);x InternationalConventionfortheSuppressionoftheFinancingofTerrorism;x ResolutionsandDecisionsagainstnarcoticabuseandaddictionoftheWorldHealth

Organization(WHO)andtheWorldHealthAssembly. Drug supply and demand reduction are regulated by relevant international and nationalinstruments, which are being continuously improved to increase the effectiveness ofresponses in this area. The country´s fundamental legal framework for combating drugabuse and illicit trafficking consists of the following basic legal acts: the Criminal CodeArticles 215 and 216; the Law for Criminal Procedures; and the Law for CombatingNarcoticsandPsychotropicSubstances.

1.1.1. CriminalCodeArticles215and216The Act covers illicit possession, production, trafficking, acting as a mediator in sale orpurchase and any other type of trading in drugs, and also regulates criminal offencescommittedundertheinfluenceofdrugs.Significant changes have been made in recent years to harmonise legislation with

EuropeanUnion(EU)directives.Intheareaofdrugs,importantchangesweremadetothe

 

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penaltiesimposedforthecriminaloffenceslistedbelow.TheLawforCriminalProcedurestates:

Unauthorised production and sale of narcotic drugs, psychotropic substances andprecursors,Article215(1)Apersonwhowithoutauthorisationmanufactures,processes,sellsoroffersforsaleorforbuy,holdsortransmitsormediates inthesaleorpurchaseorotherwiseunauthorisedcirculatesnarcoticdrugs,psychotropicsubstancesandprecursors, shallbepunishedwithimprisonmentofthreeto10years.(2)Iftheoffenceunderparagraph(1)ofthisArticlerelatestosmalleramountsofnarcoticdrugs,psychotropicsubstancesandprecursors, thisshallbepunishedwith imprisonmentofbetweensixmonthsandthreeyears.(3)Iftheoffenceunderparagraph(1)iscommittedbyseveralpersons,ortheperpetratorof thiscrimeispartofanorganisednetworkofresellersoragents, thisshallbepunishedwithimprisonmentofatleastfiveyears.(4)Apersonwho,withoutauthorisation,purchases,mediatesorgives foruseequipment,material or substances known to be intended for the production of narcotic drugs,psychotropicsubstancesandprecursorsshallbepunishedwithimprisonmentofonetofiveyears.(5)Theperpetratorof offences underparagraph (2), except the organiser,whodisclosestheactorcontributestoitsdisclosure,wouldbeexemptfrompunishment.(6)Ifthecrimeiscommittedbyalegalpersontheyshallbepunishedbyafine.(7)Narcoticdrugs,psychotropicsubstancesandprecursors,aswellasmovableorimmovableobjectsusedfortheirmaking,transmissionanddistribution,willbeconfiscated.

Facilitatingtheuseofnarcotics,Article216(1)Theuse of other narcotic drugs, psychotropic substances or precursors and giving ofnarcotic drugs andpsychotropic substances to any other person for their use, ormakingavailable facilities for the use of narcotic drugs, psychotropic substances or otherwiseenablinganotherpersontousenarcoticdrugsshallbepunishedwithimprisonmentofonetofiveyears.(2)Ifthecrimeiscommittedagainstaminororagainstseveralpersonsorcausesespeciallygraveconsequences,itshallbepunishedwithimprisonmentofoneto10years.(3)Ifthecrimeiscommittedbyalegalpersonitshallbepunishedbyafine.(4) Narcotic drugs andmovable or immovable property used for their transmission anddistribution,orspecificallydesignedormadeforuse,willbeconfiscated.

ItisimportanttounderlinethattheLawalsoallowsforalternativemeasurestobeapplied(Article48),asacriminalchargecannotbeappliedtominoroffenceswhennotrequiredbycriminaljusticeandwhenitisexpectedthatthepurposeofpunishmentcanbeachievedbygiving a warning about the threat of punishment (probation), a caution (judicialadmonition) or measures to assist and supervise the conduct of the offender in thecommunity. Alternative measures (Article 48‐a) include: probation; probation withsupervision; termination of the criminal proceedings; community service; judicialreprimand;andhousearrest.

 

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1.1.2CriminalProcedureLawTheCriminalProcedureLawhasundergonesignificantchangesthathaveincreasedthe

powersofthepublicprosecutor,andtheentireinvestigativeprocess.Thelawwasinitiallypassed in 2010, but was delayed twicewhile preparationsweremade to implement itsprovisions. Article 41 details the leading role of the public prosecutor in pre‐trialproceedings,namelythat,forthepurposeofcriminalprosecution,theprosecutormanagesthepre‐trialproceedingsandtheJudicialPolice.The public prosecutor can take any action necessary to detect crime and in the

prosecution of the perpetrator that is authorised by law authorities. The CriminalProcedure Law permits the establishment of investigation centres. Employees who areselected towork in the investigationcentresareavailable to thepublicprosecutor.Theyworkunderthepublicprosecutor’ssupervisionandcontrol,observeandcarryouthis/herorders, and follow his/her directions and instructions. A new development is theestablishment of the Judicial Police, which, ex officio or on the order of the publicprosecutor,undertakemeasuresandactivitiestodetectcriminaloffences,preventfurtherconsequencesofcrimes, captureandarrestperpetrators,provideevidenceandcarryoutothermeasuresandactivitiestofacilitatethesmoothconductofthecriminalproceedings.1.1.3.LawforCombatingNarcoticsandPsychotropicSubstances

InaccordancewiththeActonCombatingDrugAbuse(Article21),theMinisterofHealthcreatedthe ‘Listofdrugs,psychotropicsubstancesandplantsusedtoproducedrugsandsubstancesthatcanbeusedintheproductionofdrugs’.TheListisregularlyupdatedinlinewiththerelevantinternationalandEUregulationsandnationalriskassessmentprocedure.1.1.4.AdoptionofamendmentstotheListofControlledSubstancesA ‘new psychoactive substance’ is a narcotic or psychotropic drug, in pure form or inpreparation, that is not controlled by the 1961 United Nations Single Convention onNarcotic Drugs or the 1971 UnitedNations Convention on Psychotropic Substances, butwhichmaypose a public health threat comparable to that posedby substances listed intheseconventions. Basedonthenationalriskassessmentprocedure,andespeciallytheappearanceonthe

drug market of MDPV 3,4‐methylenedioxypyrovalerone, the national List of ControlledSubstanceswasamended(15‐1879/1)inMarch2014bytheMinisterofHealthtobring15substancesunderlegalcontrol. Substances under control in the List of Psychotropic Substances (synthetic drugsunder national control equivalent to those for the substances in UN71 Schedule I), forwhich there is also a risk assessment under the Joint Action that has resulted in pan‐Europeancontrols,are:

x 4‐MTA,4‐Methylthioamphetamine;x PMMA,para‐Methoxymethamphetamine;x 2C‐I,2,5‐dimethoxy‐4‐iodophenethylamine(psychedelicphenethylamine);

 

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x 2C‐T‐2,2,5‐dimethoxy‐4‐ethylthiophenethylamine;x 2C‐T‐72,5‐dimethoxy‐4‐propylthiophenethylamine (psychedelicphenethylamine);x TMA‐2trimethoxyamphetamines.

The substances that are under control in the List of Narcotic Drugs (under national

controlsequivalenttothoseforthesubstancesinUN61ScheduleI)includenewsubstancethatgiverise toconcern.TheEuropeanMonitoringCentre forDrugsandDrugAddiction(EMCDDA)andEuropolhavedrawnupJointReportsonthesesubstances(1):

x mCPP(1‐(3‐chlorophenyl)piperazine);x BZP(1‐Benzylpiperazine);x mephedrone(4‐methylmethcathinone);x 4‐MA(4‐methylamphetamine);x 5‐IT(5‐(2‐aminopropyl)indole);x methoxetamine(2‐(3‐Methoxyphenyl)‐2‐(ethylamino)cyclohexanone);x AH‐7921(3,4‐dichloro‐N‐[[1‐(dimethylamino)cyclohexyl]methyl]benzamide);x 25I‐NBOMe(4‐iodo‐2,5‐dimethoxy‐N‐(2‐methoxybenzyl)phenethylamine);x MDPV(3,4‐methylenedioxypyrovalerone).

1.2.NationalStrategyandActionPlan:evaluationandcoordination

1.2.1.NationalDrugsStrategy(2006–12)andActionPlan

InDecember2006 theParliament adopted the firstnational strategyondrug‐relatedissues. The National Drugs Strategy (2006–12) was based on the relevant internationalconventionsandlegalactsondrugcontrol,andsetnationalprioritiesfordealingwiththisproblem.

The Strategy advocated an integrated, multidisciplinary and balanced approach totacklingthedrugsphenomenon.ItsstructureisillustratedinFigure1.1.

                                                            (1)http://www.emcdda.europa.eu/publications/searchresults?action=list&type=PUBLICATIONS&SERIES_PUB=a105

 

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Figure1.1.StructureoftheNationalDrugsStrategy(2006–12).

1.2.2.ImplementationoftheStrategyandActionPlan The Strategy and its Action Plan were implemented between 2006 and 2012.

Implementation was assessed annually on the basis of various (standardised and non‐standardised) reports from proficient ministries, institutions and civil societyorganisations.TheActionPlanspecified individualmeasuresandactions thatwere tobetaken, the institutions responsible for their implementation, and their deadlines andindicators.Relevantinstitutionswereobligedtoreportontheprogressmadeinthegivenperiod to the Inter‐ministerial Commission for Narcotic Drugs. The Department forControlled Substances in the Ministry of Health analysed progress in implementingstrategicdocumentsaswellasingeneralevaluation;itsfindingswerepresentedtotheEUCommissioneverysixmonths,andtotheMiniDublinGroup(accreditedforeigndiplomatsinthecountry).The Department for Controlled Substances monitored trends using a variety of

indicators,and,whennecessary,proposedadditionalmeasuresorchangestotheplannedactionsinthegivenperiod.At the national level, programmes implemented by civil society organisations were

evaluatedbyexternalevaluators,sinceconsiderablefinancialresourceshadbeenallocatedtothemfromthebudgetoftheGlobalFundtoFightAIDS,TuberculosisandMalaria(‘theGlobalFund’).Programmes in the fieldsofdrugdemandreductionanddrugspreventionthat were implemented at the local level were often evaluated by local Committees onCombatingDrugsAbuse(internallyorexternally)sincetheyfinancesuchprogrammes,orbytheAgencyforYouthandSportsforactivitiesfinancedbythatbody.

 

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1.2.3.EvaluationoftheStrategyandActionPlanInMay2012theDepartmentforControlledSubstances,MinistryofHealthcarriedouta

scientificevaluationoftheStrategy.Itsintentionwastoalignthenewstrategyfor2014–20withthespecificneedsarisingfromdrug‐relatedproblems,andtoimprovetheefficiencyoftheentiresystemofcombatingthedrugsphenomenon.1.2.3.1.SurveyconductedincooperationwiththeMinistryofHealth,MinistryofInternalAffairsandFacultyofSecuritytoassessthedrugssituation(2)In2012researchwascarriedoutusingasurveymethodthatincludedaquestionnaire

standardised foruse inEU countries, adapted to thenational circumstances.The samplesizeoftheresearchwas246people,ineightregions(20cities).Theresearchtookplaceinavarietyoflocations,bothpublicandprivate,includingparks,cafesandclubs.ResultsThe average age of respondents was 32.2 ± 7.3 years. The calculated mean values

indicatethat50%ofsurveyrespondentswereagedover32.Table1.1.Distributionofrespondentsbygenderandlocation. City Male Female Total

N % N % N %Kumanovo 30 12.20 5 2.03 35 14.23Ohrid 24 9.76 6 2.44 30 12.20Skopje 27 10.98 3 1.22 30 12.20Stip 22 8.94 8 3.25 30 12.20Strumica 30 12.20 0 0.00 30 12.20Tetovo 26 10.57 4 1.63 30 12.20Veles 21 8.54 9 3.66 30 12.20Bitola 27 10.98 4 1.63 31 12.60Total 207 84.15 39 15.85 246 100.00AccordingtoTable1.2,dataonageweresuppliedby239(97.15%)of246respondents.Theyoungestrespondentwas17yearsold,andtheeldestwas55.Table1.2.Distributionofrespondentsbyage. N Mean Median Mode Minimum Maximum StdDev.Age 239 32.2 32.0 32.0 17.0 55.0 7.3                                                            (2)T.Petrushevska,L.J.TodorovskiandV.V.Stefanovska(2012),‘DrugabuseamongyouthinMacedonia’,ArchivesofPublicHealthoftheFormerYugoslavRepublicofMacedonia(2),ISSN1857‐7148,p.54.

 

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Table1.3.Distributionofrespondentsbygenderandage.Gender Age Total

16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–55Male 4 32 45 56 35 17 8 4 201

1.67% 13.39% 18.83% 23.43% 14.64% 7.11% 3.35% 1.67% 84.10%Female 1 8 13 9 5 1 1 0 38

0.42% 3.35% 5.44% 3.77% 2.09% 0.42% 0.42% 0.00% 15.90%Total 5 40 58 65 40 18 9 4 239

2.09% 16.74 % 24.27% 27.20 % 16.74 % 7.53 % 3.77 % 1.67% 100.00 %Table1.4.Distributionofrespondentsbygenderandeducation.EEdduuccaattiioonnddeeggrreeee

MMaallee FFeemmaallee TToottaall

Incomplete

12 3 154.96% 1.24% 6.20%

Primary 66 9 7527.27% 3.72% 30.99%

Secondary 123 24 14750.83% 9.92% 60.74 %

Higher 1 0 10.41% 0.00% 0.41%

Faculty

2 1 30.83% 0.41% 1.24%

Unknown 1 0 10.41% 0.00% 0.41%

Total 205 37 24284.71% 15.29% 100.00 %

Table1.5.Distributionofrespondentsbygenderanddurationofheroinuse.Useofheroininyears

Male Female Total

Upto1 14 0 145.79% 0.00% 5.79%

1–5 54 10 6422.31% 4.13% 26.45%

5–10 60 20 8024.79% 8.26% 33.06%

10andover 75 9 8430.99% 3.72% 34.71 %

Total

203 39 24283.88% 16.12% 100.00%

The Pearson Chi‐square: 9.18488, df = 3, p> 0.05 (CI 95 %) showed no statisticallysignificantdifferencebetweengenderandthedurationofheroinuse.Table1.6.Thepriceof1gofheroin. N Mean Median Minimum Maximum StdDev.Price(MKD) 160 1239.4 1200.0 300.0 3 000.0 437.6

 

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Dataonthepriceof1gofheroinweresuppliedby160(65%)ofthe246respondents.TheminimumpricewasMKD300.0andthemaximumwasMKD3000.0(3).TheaveragepricewasMKD1239.4±437.6.Thecalculatedmeanvalues indicate that50%of respondentshadpaidoverMKD1200for1gofheroin. Table1.7.Thepriceof1gofmarijuana. N Mean Median Minimum Maximum StdDev.Price(MKD) 154 166.5 150.0 60.0 600.0 88.7Dataonthepriceof1gofmarijuanaweresuppliedby154(62.6%)of246respondents.TheminimumpricewasMKD60.0,andthemaximumwasMKD600.0.TheaveragepricewasMKD166.5±88.7.Thecalculatedmeanvaluesindicatethat50%ofrespondentshadpaidoverMKD150for1gofmarijuana. Table1.8.Thepriceof1gofmethadone.

N Mean Median Minimum Maximum StdDev.

Price(MKD) 53 299.4 120.0 50.0 1 000.0 290.7 Dataonthepriceof1gmethadoneweresuppliedby53(21.5%)ofthe246respondents.TheminimumpricewasMKD50.0,andthemaximumwasMKD1000.0.TheaveragepricewasMKD299.4±290.7.Thecalculatedmeanvaluesindicatethat50%ofrespondentshadpaidoverMKD120.0for1gofmethadone.Table1.9. Theprice of one tablet of amphetamine.  N Mean Median Minimum Maximum StdDev.Price(MKD) 35 812.9 1000 250 2000 477.6

Dataonthepriceofonetabletofamphetamineweresuppliedby35(14.2%)of the246respondents.TheminimumpricewasMKD250.0,andthemaximumwasMKD2000.0.TheaveragepricewasMKD812.9 ± 477.6.The calculatedmean values indicate that 50%ofrespondentshadpaidoverMKD1000.0foronetabletofamphetamine.Table1.10.Thepriceof1gofcocaine. N Mean Median Minimum Maximum StdDev.Price(MKD) 28 3275.0 3000.0 2500.0 6000.0 707.4

Dataonthepriceof1gofcocaineweresuppliedby35(14.2%)ofthe246respondents.TheminimumpricewasMKD2500.0, and themaximumwasMKD6000.0.The averageprice was MKD3275.0 ± 707.4. The calculated mean values indicate that 50% ofrespondentshadpaidoverMKD3000.0for1gofcocaine.                                                            (3)Exchangerate:EUR1=MKD61.

 

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Table1.11.Thepriceofoneecstasytablet. N Mean Median Minimum Maximum Std Dev.Price(MKD) 51 342.2 300.0 250.0 600.0 73.1

Data on the price of one Ecstasy tablet were supplied by 51 (20.7%) of the 246respondents.TheminimumpricewasMKD250.0,andthemaximumwasMKD600.0.Theaverage price was MKD342.2 ± 73.1. The calculatedmean values indicate that 50% ofrespondentspaidoverMKD300.0foroneEcstasytablet.

Table1.12.ThepriceofLSD(onedoseofca.80mg).  N Mean Median Minimum Maximum StdDev.Price(MKD) 7 515.0 400.0 300.0 1200.0 333.3Data on the price of LSD were supplied by seven (2.8%) of the 246 respondents. Theminimum pricewasMKD300.0, and themaximumwasMKD1200.0. The average pricewasMKD515.0 ± 333.3. The calculatedmean values indicate that 50% of respondentspaidoverMKD400.00forLSD.Table1.13.Distributionofrespondentsbygenderandfrequencyofheronuse.Gender Frequencyofheronuse Total

Onceormore amonth

Once or more aweek

Every day

Male 48 71 49 16823.65% 34.98% 24.14 % 82.76 %

Female 14 11 10 356.90% 5.42% 4.93% 17.24%

Total 62 82 59 20330.54% 40.39% 29.06% 100.00%

The Pearson Chi‐square: 2.08381, df = 2, p> 0.05 (CI 95 %) showed no statisticallysignificantdifferencebetweengenderandfrequencyofheroinuse. Table 1.14. Distributionofrespondents bygender and usual wayoftaking drugs. Gender Theusualwayofconsumingdrug Total

Intravenously Snuffing Smoking Oral Other

Male 96 45 64 1 1 20739.02% 18.29% 26.02% 0.41% 0.41% 84.15%

Female

15 15 9 0 0 396.10% 6.10% 3.66 % 0.00 % 0.00 % 15.85 %

Total 111 60 73 1 1 24645.12% 24.39% 29.67 % 0.41 % 0.41 % 100.00%

The Pearson Chi‐square: 5.27492, df = 4, p> 0.05 (CI 95 %) showed no statisticallysignificantdifferencebetweengenderandwayoftakingdrugs.

 

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Figure1.2.Distributionofrespondentsinjectingdrugs,bycity.

Table1.15.Distributionofrespondentsbyageanddrugsupplyroute.Age Routeofsupply

TotalDealer Friend Partner Internet Smartshop

16–20 0 3 1 1 0 50.00% 1.26 % 0.42% 0.42 % 0.00 % 2.09 %

21–25 17 19 2 1 1 407.11% 7.95% 0.84% 0.42% 0.42% 16.74%

26–30 42 13 2 0 1 5817.57% 5.44% 0.84% 0.00% 0.42% 24.27%

31–35 49 12 1 1 2 6520.50% 5.02% 0.42% 0.42% 0.84% 27.20%

36–40 31 6 0 0 3 4012.97% 2.51 % 0.00% 0.00 % 1.26 % 16.74 %

41–45 15 3 0 0 0 186.28% 1.26% 0.00% 0.00% 0.00% 7.53%

46–50 7 1 1 0 0 92.93% 0.42% 0.42% 0.00% 0.00% 3.77%

51–55 3 1 0 0 0 41.26% 0.42% 0.00% 0.00% 0.00% 1.67%

Total 164 58 7 3 7 23968.62% 24.27 % 2.93% 1.26 % 2.93 % 100.00 %

The Pearson Chi‐square: 54.4163, df = 28, p <0.01 (CI 99 %) showed no statisticallysignificantdifferencebetweenagegroupsanddrugsupplyroute.Theanalysisshowednostatisticallysignificantdifferenceinthedrugsupplyrouteandgender(3.13254,df=4,p>0.05(CI95%). 

 

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Table1.16.Distributionofrespondentsbygenderandplacewheredrugispurchased.Gender Placewheredrugispurchased Total

Homedelivery

Openpublicplace

Placeclosedtopublic

Indealer’shouse

Other

Male

0 3 1 1 0 50.00% 1.26% 0.42% 0.42% 0.00% 2.09%

Female

17 19 2 1 1 407.11% 7.95% 0.84 % 0.42 % 0.42 % 16.74%

Total 42 13 2 0 1 5817.57% 5.44% 0.84% 0.00% 0.42% 24.27%

ThePearsonChi‐square:11.3016,df=5,p<0.05(CI95%)showednostatisticallysignificantdifferencebetweengenderandtheplacewherethedrugwaspurchased.Table1.17.Distributionofrespondentsbycityandeaseofaccesstodrugs.City  Accessto drugs Total 

Fully  available 

Very easilyavailable 

Readilyavailable 

Hardlyavailable 

Notknown 

Kumanovo 8 13 13 1 0 353.25% 5.28% 5.28% 0.41% 0.00% 14.23%

Ohrid 3 1 4 21 1 301.22% 0.41% 1.63 % 8.54 % 0.41 % 12.20%

Skopje 0 3 14 12 1 300.00% 1.22% 5.69% 4.88% 0.41% 12.20%

Shtip 1 1 10 3 15 300.41% 0.41% 4.07% 1.22% 6.10% 12.20%

Strumica 4 4 10 7 5 301.63% 1.63% 4.07 % 2.85 % 2.03 % 12.20%

Tetovo 8 0 5 12 5 303.25% 0.00% 2.03% 4.88% 2.03% 12.20%

Veles 0 3 14 12 1 300.00% 1.22% 5.69% 4.88% 0.41% 12.20%

Bitola 16 1 7 7 0 316.50% 0.41% 2.85 % 2.85 % 0.00 % 12.60%

Total 40 26 77 75 28 24616.26 %  10.57 %  31.30 %  30.49 %  11.38 %  100.00 % 

 The Pearson Chi‐square: 168.196, df = 28 p <0.01 (CI 99 %) showed no statisticallysignificantdifferencebetweenthecityandtheavailabilityofdrugs.Theanalysisshowednostatisticallysignificantdifferencebetweenageandavailabilityofdrugs(46.2968,df=28,p>0.05(CI95%). Table1.18.Distributionofrespondentsbynumberoffriendswhotakedrugs. N Mean Median Mode Frequency Min. Max. StdDev.Numberoffriendswhotakedrugs

239 10.6 7.0 10.0 43 0.00 100.0 14.6

 

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Data on the number of respondents’ friends who take drugs were supplied by 239(97.15%)ofthe246respondents.Theminimumnumberwaszero,andthemaximalwas100. The average number of friends who take drugs was 10.6 ± 14.6. Over 50% ofrespondents hadmore than seven friendswho take drugs. Themajority of respondents(over43)had10friendswhotakedrugs.Figure1.3.Correlationbetweennumberoffriendswhotakedrugs,andageofrespondent.

Therewasnostatisticallysignificantdirectlinearrelationship(p<0.05)betweentheageofaddictsandthenumberoffriendswhotakedrugs.Withtheincreasingageofaddicts,thenumberoffriendswhotakedrugsalsoincreased.

1.2.3.2.EvaluationoftheStrategy’simplementation Summary Thepurposeofevaluationwastoascertainthecurrentstatusofdrugabuseinthecountry,toidentifywhetherthereweresignificantchangesbeforeandaftertheStrategy’sadoption.Theevaluationassessedeachofthefivefundamentalpillarsofthestrategy:coordinationofdrug policies; demand reduction; supply reduction; cooperation with internationalorganisations;andresearchandevaluation.Anadditionalobjectivewasto identifyissues

 

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that would need to be addressed by measures and activities in the subsequent drugstrategy,forcapacitybuilding.Materialsandmethods:Theresearchusedbothqualitativeandquantitativemethods,

andwasconductedbetweenJanuaryandMarch2013.Thefirstpartofthestudyanalysedresearch reports on drug‐related problems. Qualitative research was conducted in twoparts: a semi‐structured questionnaire using three focus groups of 45 people in Skopje,Tetovo and Bitola; and a research survey with a standard questionnaire tailored to theneeds,conductedwith76peoplewhowereinvolvedintheimplementationoftheNationalDrugs Strategy. Participants in the studywere selected according to theirwillingness toparticipate.Results:64.9%of respondentssaid that theStrategyhad increased theavailabilityof

treatmentprogrammes;58.4%saidthataccessibilityhadimproved;44.2%saidthatthequality of services had improved; 41.6% said that the diversity of programmes hadimproved. A total of 75.3 % stated that there was better cooperation and exchange ofinformationandthatpoliceactivityhadreducedthesupplyofdrugs.Qualitativeevaluation

The targetgroupwas inspectors from theDepartmentof InternalAffairs, 15 in eachregional area (seven fromuniformedpolice, responsible for public order andpeace, andeightfromtheUnitagainstDrugTrafficking).Quantitativeevaluation

The quantitative evaluation recruited 80 respondents who were involved in

implementingtheNationalDrugsStrategyfrompublicandprivatemedicalcentres(publichealthcentres,CentresfortheTreatmentandHarmReductionofDrugAddiction,theClinicofToxicologyandtheDepartmentofInfectiousDiseases),non‐governmentalorganisations(NGOs) active in the drugs field, the Red Cross, Government departments (Ministries ofHealth, Interior,LabourandSocialPolicy,Education,CustomsAdministration,Agency forYouthandSports)andthePublicProsecutorforOrganisedCrime.Research instruments: For the first qualitative study, a semi‐structured questionnairewas designed specifically for this type of research (focus groups). The issues discussedwithinthefocusgroupswere:

x In what locations do you find drug users who violate the public order? (Forexample:Inparks,discos,onthestreet.)

x What are the most common forms of drug use in those locations? (Injecting,smoking using foil, tablets, legally authorised medicines containing controlledsubstancesorsyntheticdrugs.)

x Do you have information on where drugs are purchased? (Dealers, friend, closefamily,partner.)

 

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x Doyouhaveexperience,aspoliceofficers,ofadrugaddictwhohasoverdosed?Ifso,howdidyouhandlethesituation–doyouhaveastandardoperatingprocedure?

x Areyouawareofthecost,qualityandpurityofdrugsthatarecommonlyabused?x Isthereadifferenceinthetypesofareathataremostcommonlyusedbydrugusers

whoviolatepublicorder?(Centralcityarea,particularneighbourhoods–which?)x Is there aparticulardayof theweekonwhich thenumberof violationsofpublic

orderundertheinfluenceofdrugsreachesapeak?x Is thereacorrelationbetweenthe timeofyearandnumberofviolationsofpublic

orderundertheinfluenceofdrugs?x What is your knowledge of new types of psychoactive substances? Are they

currentlyavailableinthecountry?x Whatexperiencesdoyouhaveofthetrendinmultipledruguse?(Heroin,cocaine,

marijuana,amphetamines,ecstasy.)x 'Doyouknowwhichdrugsareusedmostfrequently?x Doyouknowabouttheabuseofmethadonebyinjection?x Do you have any information about wheremethadone users purchase the drug?

(Pharmacy,treatmentcentre,the‘blackmarket’.)x Whatproblems,ifany,doyoufaceincarryingoutyourtasksandactivities?x Do you have any suggestions, proposals, measures or actions that could be

implementedtoovercometheseproblems?x Doyouneedadditionaltrainingorinformation,ormoreknowledgeaboutdrugs?x DoestheMinistryofInternalAffairsprovideyouwithsufficienteducation,orwould

itbeusefulifplansforadditionaldrugseducationwereincludedinthenewdrugsstrategy?

Participation in the qualitative research was voluntary. All participants were informedabouttheconfidentialityofinformationreceivedinrelationtotheirguaranteedanonymityinresearch.Focusgroupparticipantssignedinformedconsenttoensuretheywerefamiliarwiththegoalsofthefocusgroupandthatparticipationinthediscussionswasvoluntary.Thefindingsoftheresearchwereasfollows:

x Parksarethemostcommonlocationofdruguserswhoviolatethepublicorder.x Themostcommonformsofdrugusearebyinjection,andsmokingheroinonfoil.x Young people often use synthetic drugs in combination with alcohol and legally

authorised medicines containing controlled substances (often tramadol anddiazepam)at‘technoparties’.

x Drugsarepurchasedfromdealers.x The number of violations of public order under the influence of drugs reaches a

peakatweekends.x Marijuanaisthemostcommonlyuseddrug,followedbyheroinandsyntheticdrugs.x Inmanycases,methadoneabuserspurchasethedrugsfromapharmacy,andfrom

centresthattreatdependence.

 

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x Three focus groups highlighted the need for more training for police officers,particularlyaboutnewdrugs.

ThequantitativeresearchwasconductedusingastandardsurveyquestionnaireusedtoanalyseEUdrugsstrategy,adaptedtothenationallevel.Thequestionnaireconsistsof76questions covering the fivepillarsof theStrategy: coordinationofdrugpolicies;demandreduction; supply reduction; cooperation with international organisations; and researchandevaluation.Atotalof80respondentswererecruitedwhowereinvolvedintheimplementationoftheNationalDrugsStrategy.Theyincludedmenandwomenwithdifferentlevelsofeducation,national and ethnic backgrounds and position in their organisation. Respondents wereselected according to their willingness to participate, and whether they possessedinformationofinteresttotheresearch.Figure1.4.CompatibilityoftheNationalDrugsStrategywithEUstandards.

Table1.19.OpinionsonimprovementoftheNationalDrugsStrategy.

NationalDrugsStrategyandActionPlan:

Stronglyagree(%)

Agree(%)

Disagree(%)

Stronglydisagree(%)

Idonotknow(%)

Coverallrelevantissues 19.48 44.15 5.19 1.30 29.87HavebeenpreparedinaccordancewithEUstandards

19.48 48.05 2.60 / 29.87

ComplywiththeDrugsStrategyandActionPlansoftheEU

19.48 48.05 1.30 / 31.17

 

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Figure 1.5.Achievements of theNationalDrugs Strategy in improving access to and thequality ofprogrammestotreatdrugaddicts.

Figure 1.6. Are there barriers that slow down the process of tackling organised criminal groups’involvementindrugproductionandtrafficking?

Figure 1.7. 'Does the new National Drugs Strategy need to include additional tools to solve theproblemoforganisedcrime'sinvolvementintheillicitproductionandtraffickingofdrugs?

 

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Figure1.8.WhichofthesefactorshaveimprovedfollowingtheimplementationoftheNationalDrugsStrategy?

Figure1.9.WhatshouldtheprioritiesbeforthenewNationalDrugsStrategy?

FollowingtheadoptionoftheNationalDrugsStrategy,theCentreforMonitoringDrugs

and Drug Addiction was established within the Department for Controlled Substances,Ministry of Health, as a centre for cooperation with the EMCDDA. The results of thequantitative survey showed an improvement in the collection and processing of datarelated todrugs issues. TheCentre analyseddata ondrugs fromall relevant institutionsand organisations in the public, private and non‐governmental sectors. With theimplementation of three consecutive EU Instrument for Pre‐Accession Assistance (IPA)projects designed to build national capacity for collecting and evaluating drug data, thecountry isreadytocollectdata relating to the fiveepidemiological indicatorsandsupplyindicators,toprocess,evaluateandpresentinformationaboutthecurrentdrugssituation.

 

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Figure1.10.FollowingtheadoptionoftheNationalDrugsStrategy,hastherebeenanimprovementinthecollectionandanalysisofrelevantdataondrugs?

Asignificantnumberofmemorandums,protocolsandagreementsforcooperationwere

signed within the implementation of the first National Drugs Strategy. This period ischaracterisedby theharmonisationofthecountry’s legislationwithEU legislation.Therewas a significant reduction in drug‐related crime and drug demand, and activitieswerecarried out to prevent initiation of drug use, to reduce the adverse health and socialconsequences and to increase the availability of treatment in 10 cities in the country.Substantial work has been done to prevent the transmission of blood‐borne diseases,especially human immunodeficiency virus (HIV) and hepatitis. However, furtherstrengthening is needed of public health and social services, the capacity of forensiclaboratoriesfordrugprofiling,andeducationandtraining.

1.3. Coordinationmechanism Under the Law on the Control of Drugs and Psychotropic Substances the Governmentestablishedaninter‐ministerialStatecommissiontotackletheillegalproduction,tradeandabuse of drugs (the Inter‐ministerial Commission for Narcotic Drugs). The Bureau ofMedicines in the Ministry of Health conducts the expert and administrative activitiesrelatedtoitswork.1.3.1.TheInter‐ministerialCommissionforNarcoticDrugs

The Inter‐ministerial Commission for Narcotic Drugs (IMCND) consists ofrepresentativesof theMinistryof Justice,Ministryof InternalAffairs,MinistryofHealth,MinistryofLocalGovernment,MinistryofEnvironmentandSpatialPlanning,MinistryofForeign Affairs,Ministry of Education and Science,Ministry of Labour and Social Policy,Ministry of Agriculture, Forestry andWater Economy, Ministry of Finance, the CustomsOfficeandtheAgencyforYouthandSports.

The IMCND is a consultative body to the Government and its area of work,competencesandcompositionareregulatedbytheLawontheControlofNarcoticDrugsandPsychotropicSubstances.

 

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Itsmaintasksinclude:1) To analyse the drug situation in the country and provide recommendations and

proposalsrelatedtotheimplementationofinternationalconventionsforthecontrolofnarcoticdrugsandotherrelatedprescriptionsandmechanisms.

2) To develop and ensure systematic implementation of the supervision strategy ofnarcoticdrugs,thepreventionandsuppressionofabuseofnarcoticdrugs.

3) Topromotepreventiveactionsandpublicinformationrelatedtothedamagecausedbytheuseofnarcoticdrugs.

4) Toimplementasystemfordatacollectionanddataprocessingrelatedtothenatureandwidespreademergenceofnarcoticdrugabuse.

5) Tocoordinateandsupporttheactivitiesoflocalandregionalunits.6) Toreviewthelawsandotherprescriptionsandmechanismsthatarerelatedtothe

issuesofabuseanddamagecausedbynarcoticdruguse.7) Topropagatetheimplementationoftheinternationalobligations.8) TorepresenttheGovernmentininternationalbodiesandtodeliverreportsanddata

inaccordancewithinternationalconventionsforthecontrolofnarcoticdrugs,andto ensure the maintenance of regular communication with domestic and foreignspecialisedbodiesanddepartments.

9) Tosubmitreportsonthecurrentsituationandtrendsonthesupplyofanddemandfornarcoticdrugs,withrecommendationsforrelevantproposalsandactionstobeundertakenbystateadministrationbodies.

TheIMCNDisalsoresponsibleforcarryingoutothertasksdelegatedbytheGovernment.Figure1.11.OrganisationalstructureoftheIMCND.

NNAATTIIOONNAALL GGOOVVEERRNNMMEENNTT

INTER-MINISTERIAL COMMISSION FOR NARCOTIC DRUGS

 MINISTRY OF HEALTH

MINISTRY OF AGRICULTURE MINISTRY OF EDUCATION AND SCIENCE 

MINISTRY OF HEALTH

MINISTRY OF INTERIOR

MINISTRY OF LOCAL GOVERNMENT MINISTRY OF ECONOMY, CUSTOMS ADMINISTRATION

MINISTRY OF JUSTICE MINISTRY OF FOREIGN AFFAIRS  

AGENCY FOR YOUTH AND SPORTS MINISTRY OF SOCIAL WELFARE

 

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TheIMCNDsetsouttangiblegoalswithinthreemainthemes:theruleoflaw;policyandtrendanalysis;andprevention,treatmentandreintegration:

x Ruleoflaw:TheIMCNDpromoteseffectiveresponsestodrugscrimebyfacilitatingthe implementation of relevant international legal instruments, andbypromotingeffective, fair criminal justice systems through the use and application of UnitedNationsandEUstandardsandnormsincrimepreventionandcriminaljustice.

x Enhanced knowledge of trends for: effective policy implementation, operationalresponse and impact assessment in drugs and crime; risk analysis; scientific andforensicanalysis.

x Effectivedataanalysis:InaccordancewiththeNationalDrugsStrategy,theIMCNDreviews and adopts the reports issued by the national focal point (NFP) at theDepartment for Controlled Substances, Ministry of Health, and by otherdepartments including the Ministry of Internal Affairs and the CustomAdministration. Reports are based on surveys, drug addiction data and trendanalysis, seizures, etc. Reports document the activities of governmental bodies,NGOs,expertsandintelligencesurveillance.Thisexpertisecontributestoapowerfulknowledge‐based policy analysis, coherence of programmes, quality control andknowledgemanagementsystem.

 

1.3.2.Nationalfocalpoint(NFP)   The NFP was officially created in May 2007 by the Government Decree on theEstablishmentof theCentre forMonitoringofDrugsandDrugAddictions (national focalpoint)(OfficialGazetteoftheFormerYugoslavRepublicofMacedonia,18May2007,p.2,nr.62).ThisdocumentdescribestheNFP’stasks,location,requirementsfordatacollectionquality,reporting,basicfieldsofaction,etc.TheNFPisledbytheheadoftheDepartmentforControlledSubstancesintheframeworkoftheBureauforMedicinesattheMinistryofHealth.TheNFPislocatedinthepremisesoftheMinistryofHealth. TheNationalCentreforMonitoringofDrugsandDrugAddictionsisrequiredtoprovideobjective,reliableandcomparableinformationondrugsanddrugaddictions, in linewithEU standards. The statistical and technical information and documentation produced bytheCentreis intendedtoprovideaglobalpictureofdrugsanddrugsaddictions,whichisusedasthebasisforundertakingmeasuresandplanningactivities. Theprovisionofcomparable,objectiveandreliabledatawillbeassuredbyestablishingindicators and common criteria, to increase the uniformity of the data and to establishmeasurablestandards.

TheinformationproducedbytheCentremustbestandardisedandmeetqualitativeandquantitativenorms.ProvidingdatawithsatisfactoryqualitynormsisthebasicgoaloftheCentre,sothatafullpictureofthedrugssituationcanbeprovided.TheCentreisrequiredtomonitorandevaluatedatafromthreesources:

 

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� thehealth field, including the fiveepidemiologicalhealth indicators:prevalenceofdrug use among the general population; problematic drug use; treatment; drug‐relateddeaths;anddrug‐relatedinfectiousdiseases;

� policedataasindicatorsfordrugs,� customsdataasindicatorsfordrugs.

The Centre also performs special tasks, as required and when authorised by the

MinistryofHealthorGovernment, includingscientificstudies,researchandanalyses.TheCentre cooperates with the EMCDDA and participates in the REITOX network (ReseauEuropeendInformationsurlesDroguesetlesToxicomanies). The followingbodiesprovidedata to theNFP:Ministryof InternalAffairs,MinistryofFinances,CustomsAdministration,MinistryofHealth,MinistryofEducationandScience,Ministry of Labour and Social Policy, Institute for Public Health, Institute of ForensicMedicine, Clinic for Infectious Diseases, Institute for Forensic Medicine and otherinstitutions.

1.4.TheprocessofadoptionofthenewNationalDrugsStrategy(2014–20) The new National Drugs Strategy for the period 2014–20 is in the final stages of

adoptionbytheGovernment.The Strategy and Action Plan (2014–17) were prepared by the Sector for control of

narcoticdrugs,MinistryofHealthandsubmittedforapprovaltotheIMCND.All10membersoftheIMCNDunanimouslysupportedthenewNationalDrugsStrategy

andActionPlan.During the final stages of preparation of the new Strategy and Action Plan, the draft

materialwaspresentedtoandadoptedby:x theCollegiumsheadedbytheDirectorofthePublicSecurityBureau,attendedbythe

Assistants Director and most of the Heads of Sectors of the Ministry of InternalAffairs;

x the Collegiums headed by the Assistant Director of Control and Investigation,Customs Administration, Chief of Department of Investigation, the Chief ofDepartmentforRiskManagement,andtheChiefofDepartmentAgainstSmuggling;

x thePublicProsecutorforOrganisedCrime.The draft National Drugs Strategy (2014–20) and Action Plan outline a number of

measuresandactionstotacklenewchallenges,including:

x improvingthequality,diversification(intermsofsensitivitytoculturaldifferences,gender,age,ethnicity)andavailabilityofcentresforopiatesubstitution/methadonemaintenancetreatment(MMT);

x re‐organising,decentralisingandincreasingtheavailability(fromtertiarytoprimarylevel)ofbuprenorphinetreatmentfordrugaddiction;

 

29  

x measuresandactivitiesformandatorypsychiatrictreatmentcentresandspecialisedclinicsforthetreatmentofdrugaddiction,notonlypharmacologicaltreatment(issuingopioidsubstitutiontreatment(OST));

x ensuringintegratedaccesstohealthcareandtreatmentforpsychiatricco‐morbidly;x conductingresearchandanalysisintothereasonsfortheincreasingnumberof

deathsfrommethadoneoverdose;x conductingforensicanalysistoestimatethehighincidenceofdeathsfromtraffic

accidentsandpossibleuseofpsychoactiveagentsasariskfactor;x measurestorespondtothegrowingtrendforusingmultiplepsychoactive

substancesatthesametime,includingprescriptiondrugsthatcontainpsychoactivesubstances;

x preventingthediversionofchemicalsthatcanbemisusedasprecursorsfortheproductionofillegaldrugs;

x legalinterventionstoprovideatimelyresponsetoemergingtrendsinnewpsychoactivesubstancesinEUcountries;

x legalinterventionstoestablishanearlywarningsystemfornewdrugsonthemarket,accordingtoexistingEUregulations;

x activitiestostrengthenthecapacityofforensicanalysistodeterminethepurityofandactiveingredientsinseizeddrugs;

x establishingamedicalbodytosupervisetheimplementationoftreatment(pharmacologicalandpsychiatric)forpeoplewithdrugaddiction,whichwillalsoberesponsibleforeducatingmedicalstaff.ThisbodywillbeunderthecoordinationoftheIMCND;

x establishingaspecialisedbodyforoverseeingtheimplementationofpreventiveactivitiesintheareaofdrugs,underthecoordinationoftheIMCND;

x activitiestodevelopregionalcoordinationbodies(units)intheareaofdrugs,locally,underthecoordinationoftheIMCND,inaccordancewitharticle9oftheLawontheControlofNarcoticDrugsandPsychotropicSubstances.

TheNationalDrugsStrategyisbasedontheprinciplesofhumanrights,toensureequal

opportunities for all citizens and equal access to provision that is appropriate to theirneeds.Thegreatestemphasis isgiventothepreventionofdrugaddictionandthecreationof

quality treatment programmes with mandatory psycho‐therapeutic treatment and care.TheStrategyisexpectedto:enhancecapacityandriskanalysis;ensurethemaximumuseofinstruments designed to sharing intelligence; ensure participation in joint internationalinvestigation teams; strengthen border controls; and increase active participation inregional and international initiativesandplatforms. Ithasalso introducedprocedures toprepare for the re‐socialisation of prisonerswith a drug addiction, and numerous otheractivitiesingeneral.

 

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1.5.Economicissues It is not possible to provide a comprehensive analysis of the expenditure on

implementing the National Drugs Strategy and Action Plan, because particular measureholders (Ministries) have not specified the resources allocated to activities aimed atcombating drugs abuse in their budget, but instead fund them through their regularactivities.Itisimportanttonotethatthefollowingactivities,predominantlycarriedoutbyNGOs,

are funded by the Global Fund: focused interventions, and integrated and community‐oriented approaches to ensure sustainability of services and for the implementations ofpreventive interventions amongmost‐at‐risk populations, including injecting drug users(IDUs).ThetotalfundingwasUSD8537039(4)fortheperiod2012–14. 

1.5.1.TheHealthcareProgrammeforPeoplewithAddictionsBased on Article 16, paragraph 1, item 5 and paragraph 3 of the Law on Health

Protection (Official Gazette of the Former Yugoslav Republic ofMacedonia, no. 43/2012and145/2012),theGovernmentadoptsanannualHealthcareProgrammeforPeoplewithAddictions, and approves the treatment budget. According to the available data sources,there are 20000 to 30000 drug users, ofwhich 6000 to 8000 are heroin addictswithserioushealthandsocialproblemswhoareclassedasproblemdrugusers.In 2012 the University Clinic of Toxicology, Skopje treated 140 people for opioid

addiction with the generic product buprenorphine, funded by the Ministry of Health.Approximately 30 people were treated with buprenorphine in private health facilities;thesepatientswereself‐funded,andwerenotpartoftheState‐fundedprogrammeof‘free’treatment.

TheHealthcareProgrammeisintendedforpeoplewhousedrugsoraredependentonthem. It offers widely available, efficient, flexible and individually tailored interventionsthat will improve drug users’ health and social functioning without stigmatisation.Treatment provided under the Healthcare Programme (including treatment in dayhospitals,hospital treatment for30–90days,and treatment followinga courtorder) isacombination of pharmacotherapy and psychotherapy, which is carried out following anassessmentoftheneedsoftheaddictandhisorherfamily.Socialskillstrainingtoimprovesocialfunctioningisafeatureoftheprogramme.

Ten different care packages (with different prices) are available for outpatient (dayhospital)andinpatient(residentinhospital)care.Theitemsineachcarepackagevary,butmay include: the psychiatric status of the patient; verbal intervention; history of drugtakingandmentalhealthissues(heteroanamnesis);observation(monitoringofpatienttodetermine the correct therapy); preparing and issuing OST; supervision in drinkingtherapy;measurementofvitalsigns(pulseandbloodpressure);awrittenreportaboutthepatient.

                                                            (4)http://www.aidspan.org/country_grant/MKD‐H‐MOH 

 

31  

The care packages are deliveredby teamsmadeup of doctors, psychiatrists, nurses,psychologistsandsocialworkers.Thecostofthepackagesdoesnotincludescreeningtests,medicalmaterials,prescribedtherapy,medicationsandlaboratorytests,allofwhichincuradditionalcharges.

In2013theHealthcareProgrammeprovidedfundsformethadonetreatmentfor1200people and buprenorphine for 210 people. By 2013 the number of people who wereprovidedwithbuprenorphinehadsignificantlyincreased.

Any new services for the prevention and treatment of drug abuse that are startedduringtheyearwillalsobeincludedintheHealthcareProgramme.  FINANCING:TheHealthcareProgrammeforPeoplewithAddictionsisallocatedanannualbudget according to the approved budget of the country of MKD55000000.00(EUR901639.00), of which MKD33000000.00 (EUR540983.00) is allocated to thepurchase of methadone and buprenorphine by the Ministry of Health andMKD22000000.00 (EUR360655.00) to contractual services thatwill be paid to publichealthfacilitiesfortheservicestheyprovide.

TheorganisationsthatprovidemethadonesubstitutiontherapyandbuprenorphinetherapyundertheHealthcareProgrammeare:theUniversityClinicofToxicology,Skopje;the Psychiatric Hospitals, Skopje; drug abuse treatment units within the hospitals inTetovo, Veles, Kumanovo, Strumica, Shtip, Gevgelija, Ohrid, Bitola and Kavadarci; theremandprison‘Skopje’;andIdrizovoPrizon,Skopje.

MONITORINGANDEVALUATION:TheMinistryofHealthcarriesoutregularthree‐monthlychecksonpublichealthfacilitiesthatimplementtheHealthcareProgramme.Thefacilitiesare evaluated in termsofwhether their activities are carriedout in accordancewith theProgramme’srequirements,whetherthetreatmentprogrammeshavesuitablecontrolsinplace,andwhetherappropriatemedicaldocumentationismaintained.

 

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2. DRUGUSEINTHEGENERALPOPULATIONSURVEY(GPS) 

To date, no specific survey has been conducted on drug use among the generalpopulationaccordingtoEUstandards(GlobalPopulationSurvey),duetoalackoffunds.

2.1.Druguseintheschoolandyouthpopulation2.1.1. The European School Survey Project on Alcohol and Other DrugsThe European School Survey Project on Alcohol and Other Drugs (ESPAD) is conductedwithEUschoolpupilsaged15to16everyfouryears.Thefirstsurveywascarriedoutin1995.ESPADhasbeenconductedinthecountryin1999,2008,2011and2012(5).

Inthe2011/2012schoolyeartherewere114schools,ofwhich11wereprivate,twowerereligiousandfourwerespecialschools.

The 2012 ESPAD survey(6)was only conducted in the city of Skopje (city and ruralarea) with students in the first and second year (aged 16), so its findings are notrepresentativeofthenationalpicture.Therewere32schoolsinSkopje in2012,ofwhich20 were state schools. The survey was conducted in 20 schools, and a total of 2238studentsweresurveyed.

Thereportdrawsondatafromatotalof1146studentsbornin1996(age16years).Bycomparisonin2012,accordingtotheStateStatisticalOffice,thetotalnumberofstudentsaged16was10368. Itwillbeimportanttocomparethe2012resultswiththenextESPADstudy in 2016, because in 2012 secondary schools introduced the subject of Life Skills,whichcontainsmodulesonthepreventionofdrugabuse.

Accordingtotheresultsofthe2012survey,6.6%ofrespondentshadtakensedativesprescribedbyadoctor in theprevious threeweeks, and2.5%had taken them formorethanthreeweeks.Inaddition,4.5%ofstudentsreportedusingsedativesthathadnotbeenprescribedbyadoctor. Some15.2%said that it is veryeasy toobtain sedatives (if theywantthem,theyareeasilyavailable).The2008ESPADsurvey,conductedacrosstheentireterritoryofthecountry,foundthat10.1%ofstudentshadtakentranquillizersorsedativesprescribedbythedoctorinthepreviousthreeweeks.

The2012surveyshowsadeclineintheuseofmarijuanacomparedwith2008.Atotalof8.7%reportedhavingusedmarijuanaintheirlifetime,comparedwith10.4%in2008.Atotalof6.7%hadusedmarijuanainthelast12months,while3.9%haduseditinthelastmonth.

Comparedwith2008,in2012therehasbeensomereductionintheuseofecstasyinthelastyearandlastmonth.In2012some3.75%hadusedecstasyintheirlifetime,1.6%in

                                                            (5)S.Oncheva(1999,2008),ReportESPAD,ESPAD(EuropeanSchoolSurveyProjectonAlcoholandOtherDrugs),CANInstitute.(6)S.Onchevaetal.(2012),ESPADreport,Skopje,incooperationwiththeInstituteforResearchonAlcoholandDrugsinSchoolPopulation,Sweden,asreferencetheEuropeanUnionInstituteforCAN.

 

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thelast12months,and0.96%inthelastmonth(in2008thefigureswere3.2%,2.1%and1.6%respectively).A total of 2.18% students in Skopje in 2012 reported having used inhalants in their

lifetime, 1.5% in the last year and 0.96% in the lastmonth. The reported use of otherdrugswasbelow1%, similar to the 2008 results. Regarding the results of Skopje 2008,therewasadeclineinuseofamphetamine,LSD,heroinandalcoholtakenwithtablets. With regard to how drugs are purchased, most pupils obtained them from an older

brotherorsister(7.7%),followedby:anolderfriend(5.5%);afriendofthesameageorsharedamongstapeergroup(4.3%);giventothembyastranger(4.1%);purchasedfromafriend(3.3%);purchasedfromastranger(3.2%).Whenaskedwhytheywantedtotrydrugs,10.3%saidtheywantedtofeelhigh,5.7%

werecurious,3%wantedtobeseenasbelongingtoagroup,and2.9%wantedtoforgettheirproblems.2.1.2.HealthBehaviourinSchool‐agedChildren

The Health Behaviour in School‐aged Children (HBSC) study is supported by theWorldHealthOrganizationandrepresentsalongitudinalcross‐nationalstudy.Carriedouteveryfouryears,theHBSCsurveyschildrenaged11,13and15abouttheirhealth,socialprotectionandhealthbehaviour. HBSC includes 43 countries and regions in Europe andNorth America, processesmorethan60subjectsandincludesover200000childrenandyoungpeople.HBSCfocusesonunderstandingthehealthofyoungpeopleintheirsocialcontext—athome,atschool,withfamilyandfriends—andisthemostcomprehensivepictureofthehealthandwell‐being of young people. The HBSC survey has been conducted in the country on fouroccasions—in2002,2006,2011and2013(7).

The national HBSC study, published in 2013(8), aimed to gain new insights and abetterunderstandingofthebehaviourofyoungpeople,inordertodevelopmoreeffectivepoliciesandpracticesforimprovingtheirsituation.The2013surveywasconductedonanational sample of 3897 subjects in 120 primary and secondary schools, selectedaccording to the language used to teach the children (90 schools taught in nationallanguage, 30 schools taught in Albanian), with the support ofmunicipal departments ofeducation and public health, from all regions of the country. The survey found a lowprevalence of cannabis use (4%male, 2% female) compared to the average prevalenceacross Europe and in other HBSC countries (20% male, 15% female), ranking thesenationaldatalowestamong39countries.Boysfromnon‐Albanianclasses(2.2%)weremorelikelythanboysfromAlbanianclasses(1.3%) to smoke marijuana regularly. However, there were more irregular users andexperimentersinAlbanianclasses(1.7%)thanamongtheothers(1.1%).                                                            (7) C. Curri et al. (eds) (2012), Social determinants of health andwell‐being among young people.HealthBehaviour inSchool‐aged Children (HBSC) study: international report from the 2009/2010 survey (Health Policy for Children andAdolescents,No.6),WHORegionalOfficeforEurope,Copenhagen.(8) L.KostarovaUnkovskaet al. (2013),Healthasqualityof life: social inequalitiesamongyoungpeople in thecountry.Studyonhealth‐relatedbehavioursamongschool‐agedchildren(HBSC):Report2013Skopje,CentreforPsychosocialandCrisisAction,Malinska,ISBN9789989954443.

 

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According to the analysis in the report, adolescents who began experimenting withdrugsat ayoungerageweremore likely to remain regularandheavyusers.Therewerelarge differences inmarijuana use between boys and girls, which could be explained bydifferencesinthenumberandqualityofsocialrelations,aswellasdifferencesindealingwith problems. In addition, marijuana, tobacco and alcohol were perceived as statussymbolsbyboysbutnotbygirls.TheabsenceofgirlsfromtheethnicAlbaniancommunityasusersofmarijuanamaybeexplainedbythenormsoftraditionalMuslimcommunities,inwhich young females are under constant supervision and have little involvement indecisionsmadeabouttheirlivesandhowtheyspendtheirfreetime;thisgivesthemfeweropportunities to experiment with different behaviours. Social isolation and limited timespentawayfromhomeandwithpeersinfluencethebehaviourAlbaniangirls.Thefindingsthat they increasingly smoke, but do not use alcohol and marijuana (unlike their peergroup), can be explained by their wish to enjoy themselves despite their lack ofopportunitytodosowithothersocialgroups.Althoughthenationalprevalenceofmarijuanause isrelatively lowcomparedtoother

countries, there is some concern about the findings that students are increasingly usingmarijuanaanditisincreasinglymoreprevalentandmoreeasilyavailableinyoungpeople’simmediateenvironment,includingschools.Table2.1.Frequencyofmarijuanauseamong15‐year‐olds,bygenderandlanguagetaughtinschool. Pupilswholearninthe National

languagePupilswho learn intheAlbanianlanguage

Male(%) Female(%) Male(%) Female(%)Notaregularuser 0.6 0.5 0.7 0.0Experimenter 0.5 0.4 1.3 0.0Regularuser 2.2 0.7 1.3 0.0Addict 0.6 0.2 0.0 0.0Nottried 96.0 98.2 96.6 100

2.1.2.1.Singlelifetimeuseofmarijuana,butnotinthelast12monthsor30days Gender:Moreboys(4%)thangirls(2%)hadtriedmarijuanaatleastonceintheirlifetime.Ethnicity(by language):Therewerenosignificantethnicdifferences inthepercentageofboyswhosaidtheyhadtriedmarijuanaatleastonceintheirlifetime.Familyincome:Therewasasignificantassociationbetweenprevalenceofuseofmarijuanaandfamilyincome.Boysfromclasseswithhigher‐incomefamiliesweremorelikelytousemarijuanaincomparisonwithgirls,orwithpoorerchildren.

2.1.2.2.Marijuanauseinthelast30days:currentusersanddemographicdifferences Gender:Moreboysthangirlshadusedmarijuanainthelastmonth(3%ofboysand1%ofgirls).

 

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Ethnicity(bylanguage):Anequalproportionofboysinnon‐AlbanianandAlbanianclassesreportingusingmarijuanaatleastonceinthelast30days.TherewasadifferencebetweengirlsduetonoAlbanianspeakinggirlsreportingmarijuanause.Familyincome:Therewasasignificantassociationbetweenprevalenceofcurrentusersofmarijuanaamongboysfromnon‐Albanianclassesandtheirfamilyincome,withboysfromwealthyfamiliesmorelikelytohaveusedmarijuanainthepast30days

2.1.3.Researchconductedonnegativechildhoodexperiences:arepresentativesampleofstudentsfromhighschoolsandcolleges(9)Researchon the impact of negative childhoodexperienceshasbeen conductedby the

ClinicofPsychiatry,DepartmentforChildrenandAdolescentPsychiatryinSkopje,MinistryofHealth andMinistry ofEducation, in cooperationwith theWorldHealthOrganization,RegionalOfficeforEurope.This surveywas undertakenwith 1277 students aged over 18 from a representative

sampleofhighschoolsanduniversities.Thefindingsshowahighreportedprevalenceofphysicalabuse(21%),emotionalabuse(10.8%),sexualabuse(12.7%),physicalneglect(20%) and emotionalneglect (30.6%).Both genderswereaffectedby sexual abuse, therateofphysicalneglectwashigherinmalesandtherateofemotionalneglectwashigherinfemales.Householddysfunctionwasalsocommon:10%hadwitnessedviolenttreatmentof their mother, 3.7% lived with someone who abused drugs, 10.7% lived with analcoholic, 6.9% had a household member with a mental illness, 5% had a householdmember who had been incarcerated, and 3.8% had experienced parental separation.Adverse childhood experiences were linked to health‐risk behaviours. For example,emotionalabusedoubledthelikelihoodofdrugabuse,tripledthelikelihoodofattemptingsuicide,andincreasedthelikelihoodofearlypregnancy3.5times.Physicalabuseincreasedthe likelihood of early pregnancy 8.3 times and doubled the likelihood of attemptingsuicide.Therewasageneral trend that,as thenumberofadversechildhoodexperiencesincreased, so did health‐risk behaviours, implying an association with longer‐term poorhealthoutcomes.Theresearchfoundthat5.3%ofthe1277respondentsusedoneormoreillicitdrugs.

Table2.2.Relationshipbetweensubstanceabuseandexperienceofhouseholddysfunction.First category of childhood exposure

N Physical abuse

Emotional abuse

Sexual abuse

Physical neglect

Emotional neglect

Parental divorce

Mental illnesses

Mother treated violently

Imprisonment

Substance abuse

171 60 (35.1 %)

34 (19.9 %)

35 (20.5 %)

54 (31.6 %)

83 (48.5 %)

7 (4.1 %)

33 (19.3 %)

29 (17.0 %)

11 (6.4 %)

                                                            (9) M. Raleva (2013) Survey of adverse childhood experiences among young people in the Former YugoslavRepublic ofMacedonia,WorldHealthOrganization,Geneva.

 

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3.PREVENTION

Themid‐termanalysisoftheimplementationoftheNationalDrugsStrategyandActionPlan(2006–12)foundthataddictionpreventionprogrammeshadbeenimplementedinanadhocway,withoutsystematicevaluation,andthat theyarestillnotscientificallybased.Therefore the Department for Controlled Substances, Ministry of Health created theNationalPreventionProgrammeforAddiction,whichwasadoptedbytheIMCNDandtheGovernment in 2010. The primary goal of the Programme is to combat and prevent theonsetofaddictionandat‐riskexperimentingbehaviourinchildrenandyoungpeople.Morespecifically,theProgrammeanalysesthesituationanddeterminestheneedsforaddictionprevention among children and young people, and builds an appropriate preventionsystematthenationallevelandaspartofthewiderpreventionstrategy.TheProgrammeconsists of addiction prevention sub‐programmes for pre‐school children and schoolpupils,childrenandyoungpeoplewithinthesocialcaresystem,anduniversitystudents.Inaddition, the Programme pays special attention to the evaluation of preventionprogrammes,prescribesreportingcriteriaforpreventionprogrammesatthenationalandlocal level, and prescribes criteria for projects and programmes for children and youngpeople.

3.1.Universalprevention

3.1.1.School

3.1.1.1.Introductionofanewclassprogrammeinelementaryandhighschooleducation

Followingtheadoptionoftheprogrammeforpreventionofdrugs,theBureaufortheDevelopment of Education, Ministry of Education and Science, made a systematic steptowardsthepreventionofdruguseamongyoungpeople.Anewlecturingprogrammewasintroduced as a regular class programme (Life Skills), with the objective of introducinghealthylifestylesinelementaryeducation(forchildrenaged9years),safebehaviourinthefirst years of elementary education, and, for themiddle school classes, how to dealwithpeerpressure to takepart inactivitiesandbehavioursuchas smoking,drinkingalcohol,takingsomestimulants,etc.,thatcanhaveanegativeeffectontheirhealth.Itisimportantto emphasise that the Programme suggests various techniques to inform the students,including life stories, letters from people with addiction, puzzles, quizzes, and classdiscussions(10).Youngpeopleneedtobeeducatedabouthealthybehaviourandattitudes,and encouraged to use prevention measures. This new approach is youth‐friendly, andencourages young people to talk to their parents or teachers about health and relatedissues, such as the prevention of HIV, pregnancy, drugs or other risk behaviours, ratherthandependingexclusivelyoninformationfromtheirpeergroupand/oroldersiblings.

                                                            (10)‘Lifeskillsforhighschoolstudents’worksheet,http://bro.gov.mk

 

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Thesenewdevelopments inpreventionprogrammeswithin theschoolsystemplayavery important role in motivating pupils to choose healthy lifestyles, by organisingappropriate leisureactivitiesanddevelopingself‐esteemandsocialskills.Theyalsoofferadvicetofamiliesandteachersabouthowtoidentifyapossibleproblematanearlystage,and how to prevent drug use among pupils. Teachers and coordinators of schoolpreventionprogrammesplayanimportantrole in implementingthepreventionactivitiesdevised by the Bureau for the Development of Education, Ministry of Education andScience.3.1.1.2.‘Stoptheviceamongtheyouth’project

ThispreventionprojectisimplementedbytheAgencyforYouthandSportsinmostofthemunicipalitiesinthecountry,withtheprimaryintentionofencouragingyoungpeopletoavoidnegativesituations,whilehelpingthembuildhealthyhabitsandgoodbehaviour.The project has several aims: to raise awareness among students about how to protectthemselves from and prevent negative behaviour; to educate and inform young peopleabout the negative consequences arise from such behaviour; to improve young people’sknowledge,abilityandskillsinrecognisingthesignsandsymptomsofadversebehaviourrelatingtodrugsandalcohol;andtofamiliariseyoungsterswithusefulandhealthyhabitsandlifestyles.Withintheoverallproject,47educationalworkshopswereheld.

Figure3.1.Theeducationalworkshopsproject‘Stoptheviceamongtheyouth’.

 

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The project has so far involved approximately 10000 students in Skopje and othermunicipalities. TheAgency forYouth andSportshasplans to continue to implement theprojectinothermunicipalities.

3.1.1.3.Establishingaschool‐baseddrugpreventionprogrammeinsecondaryschools,2008–11Theschool–basedpreventionprogrammewasdevelopedfollowinganassessmentofneedsin secondary schools. It found that students, teachers and parents needed moreinformationaboutdrugs,andwantedtoactivelyparticipate inschoolactivities, includingprevention programmes and mutual cooperation among them, that dealt with drugproblems.Theprocessofestablishingaschool‐baseddrugpreventionprogrammestartedinNovember2008asajointprojectbetweentheHealthyOptionsProject,SkopjeandtheTrimbos Institute, financially supported by the MATRA Programme of the NetherlandsMinistryofForeignAffairs.ThemainpartnersweretheMinistryofEducationandScience,theCityofSkopje,theMunicipalitiesofStrumicaandTetovoandthreesecondaryschools.

Theintentionwasfortheprojecttocontributetothedevelopmentofaschool‐baseddrugpreventionprogramme,toreducethelevelofriskyandproblematicdruguseamongyoung people and to raise public awareness about the unfavourable position and socialexclusion of drug users. The projectwas implemented in the followingway: local teamswereestablished inSkopje,StrumicaandTetovo;a teamofexperts inschool‐baseddrugpreventionwas established,which provided six‐weekly training for local teams; a set ofinformation materials on cannabis and alcohol was developed. The programme wasapprovedbytheschoolcouncilsandthecity/municipalitiescouncilsasapartoftheyearlyschoolprogrammefor2009/2010and2010/2011,inthethreepilotschools.Aspartoftheproject, a multi‐disciplinary expert group was established to support implementationdissemination in other schools. Training in early detection was carried out withrepresentativesfromschoolsandtreatmentcentres.Intotal,4157studentswerecoveredbythetraining.Asaresultoftheproject,schoolprotocolsweredevelopedandapprovedthat defined the roles and responsibilities of the members of the school community inrelation to alcohol/cannabis use in the pilot schools. In the last phase of the project(finalisationanddissemination),theMinistryofEducationandScienceandtheBureauforDevelopment of Education recommended that the school‐based drug preventionprogramme (including its materials, trainings etc.) should be integrated into Life Skillseducation(Dimovska2014).

 

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3.1.2.Community Addictionpreventionprogrammesareconductedatthelevelofmunicipalities,inwhich

LocalBodiesforCombatingDrugsAbuseareestablished,whicharebasedontheworkofexpertsfromthefieldsofeducation,socialwelfare,healthcare,NGOs,localadministrationofficesandotherrelevantinstitutionsthatactivelyparticipateincombatingdruguse.Prevention programmes at the local level are usually oriented towards the general

population,butalsoincludeintensiveworkwithchildrenandyoungpeoplewhopresentariskofaddictionduetotheirsocialandfamilyconditions.Experiencehasshownthatthemost effective prevention programmes are those conducted in cooperation witheducationalinstitutions,healthandsocialservices,mediaandthelocalcommunity. 

3.1.2.1.Thefirstcounsellingcentreforthepreventionofdrugabuse:WeWanttoKnowThefirstcounsellingcentre forthepreventionofdrugabuseamongsecondaryeducationpupilswasopenedinthecityofSkopje.Thisyouthcentre,WeWanttoKnow,aimstomakeyoungpeoplewhoattendfeelmoresecure,comfortableandrelaxed.Followingthecentre’sopening, the first aim in terms of primary prevention within the local strategy was ‘tostrengthentheprogrammesforthepreventionoftheabuseofdrugsamongtheyouthandto increasethedegreeofknowledgeaboutdrugsamongprofessionalsandtheparentstoworkwithyoungpeopleonthepreventionofaddiction’.Theprimaryaimoftheprojectistogiveyoungpeople,particularlythehighschoolpopulation,easieraccesstoinformationand to provide consultationsondrugpreventionandhow todealwithproblemsarisingfromdruguse.Itaimstobuildthecapacityofprofessionalservicesinschoolstoworkwithyoung people, and provides continuous professional support and resources for theprevention of drug use and early detection. It also supports education in high schoolsthroughthecreationandimplementationof localactionplansintheschools,andaimstoincrease access for young people and their parents to high‐security, anonymousconsultations with experts. The project uses networking and coordination among highschools and counselling centres, through which they have daily communication withprofessional services and access to urgent interventions. The opening of the firstcounsellingcentrewassupportedbylocalgovernments,youngpeopleandtheirparentsonallissuesrelatingtodruguse. The service presents a model of adolescent‐friendly provision that fully respects theconfidentiality, anonymity and privacy of the client. Young people want access tocounsellingforpersonalproblemandmayhaveissuesandproblemswithdrugabuse,butthey do not want to be labelled as ‘drug users’. Guaranteeing privacy and anonymitypreventsthisfromoccurring. TheWeWanttoKnowcounsellingcentreisopentwodaysperweek.Thetargetgroupincludes young people aged 10–24 (both drug users and non‐drug users), parents, closefamilymembers,andpeoplewhoworkcloselywithyoungpeopleandhaveanimpactontheir development—such as teaching staff and thoseprovidingprofessional services inhighschools(psychologistsandcounsellors).

 

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Thecentrehiresqualifiedpsychologistsandcounsellorswhoare trainedtoworkwithyoung people and who have a non‐judgemental attitude, tolerance and respect fordifferences.3.2.Selectivepreventioninat‐riskgroupsandsettings Selectivepreventionistargetedataspecificsub‐populationwithconsiderablyhigherthanaveragefutureand/orliferisksfordisorders.Thismakesit importanttoidentifytheriskfactorsfortheonsetanddevelopmentofsubstanceuse,especiallyamongyoungpeople.3.2.1.SOSDrugsHelplineThe SOSDrugsHelpline is provided by theAssociation of SocialWorkers of Skopje as apermanent service for all citizens. By calling the free number 0800 11 444 citizens canobtaininformationondifferenttypesofdrugs,theireffects,theconsequencesoftheiruse,treatment institutions at home and abroad, and information about humanimmunodeficiency virus/acquired immunedeficiency syndrome (HIV/AIDS) and sexuallytransmitted infections, and they can also arrange a free counselling session with aprofessional. TheprimarytaskoftheSOSDrugsHelplineistodevelopandpromotethepreventionofdrug use, and to assist individuals, families and friends of those who already have aproblemwithdruguse.Theexpertteam,whohaveextensiveprofessionalexperienceinthedrugs problems, receive ongoing education about tackling drug use and providingtelephoneassistance.Accordingtostatisticalanalysisoftheline’soperation,between2003and2014theSOSDrugsHelplinereceivedcallsfrom3278citizenswhoaskedover12093questions,mostofwhomwereparentsseekingadvicefortheirchildren.AnalarmingfacttoemergefromtheHelplineisthattheageof juveniledrugabusershasfallen,andmanyare in troublewith the law.A significantnumberof calls are fromyoungpeople seekinginformation about the consequences of use of various drugs and about treatmentinstitutions.Themost frequent requests for informationarehowto recognisewhetherapersonusesdrugs,whattreatmentinstitutionsareavailable,informationondifferenttypesof drugsand informationonHIV/AIDS infections.TheHelpline receives calls fromeverycityinthecountry,notjustSkopje.3.3.Indicatedprevention 

Indicated prevention attempts to identify individuals who have high individual riskfactorsfordrugabusedevelopmentintheirfuturelifeorwhoalreadyshowearlysignsofsubstanceuse.Programmesforindicatedpreventionhavebeensubstantiallyscaledupinthepastyears

through the Global Fund. The programmes target IDUs, the most at risk population,

 

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includingprisoners.Tenstationaryvoluntaryconfidential counsellingand testing(VCCT)centresandtwooutreachVCCTmobileunitsoperateindifferentregionsofthecountry.ThetwooutreachmobileunitsareoperatedbytheNGOHERA,whichhassuccessfully

establishedproductiveandcoordinatedcollaborationbetweenGovernmental institutionsand the civil society sector. The outreach programme includes all NGOs working withdifferenttargetpopulations(menwhohavesexwithmen,commercialsexworkers,IDUs,Roma,prisoners,studentsindormitories,andthegeneralpopulation)andtheInstituteforPublicHealth.Theoutreachactivitiesare tailored to theneedsand confidentialityof thespecificpopulationbyemploying ‘gatekeeper’ representatives fromthe targetgroup.Theaim of this approach is that hard‐to‐reach populations are more likely to trust therepresentativesiftheyhavesomethingincommonwiththem.Following the establishment of one additional outreach VCCT service,which operates

throughoutthecountry,therehasbeenanincreaseincoverage.Anadditionalachievementis the daily collaboration between the different NGOs and health workers, which haspractically developed into a partnership network, and can be used as model for futureactivities.

 

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4.PROBLEMDRUGUSETheEMCDDAdefinesproblemdruguse(PDU)asinjectingdruguseorlong‐term/regularuseofopiates,cocaineand/oramphetamines.Thisdefinitionspecifically includesregularorlong‐termuseofopioidssuchasmethadone,butdoesnotincluderareorirregularuse,orecstasyandcannabisuse. In 2010 various methods (expert opinions, inventory, methods of recording and re‐recording the condition, as well as methods multipliers) were used to estimate theprevalenceofinjectingdruguseinfivecities,includingSkopje. Extrapolation of the results from the IDU population in Skopje (representingapproximately25%ofthetotalpopulation)tothecountryasawholesuggestedthattherewere10200intravenousdrugusersinthecountry. The National Monitoring Centre for Drugs and Drug Addiction, Sector for ControlledSubstances, has estimated the number of problem drug users, mainly opiate users(multiplier method based on treatment programmes and needle and syringe exchangeprogrammes, contact with police and drug‐related deaths). The estimate suggests thattherearearound8000heroinIDUs.Thisfigurecorrespondstoarateof1.5usersper1000inhabitantsaged15–64(11).4.1.ImprovingthequalityofdrugdependencetreatmentprogrammesinSkopje(12)Thisreportisbasedontwointerrelatedstudiesthatindicatetheneedforimprovingthe

quality of treatment programmes for drug addiction in Skopje, funded from thenationalbudget.Thefirststudywasananalysisofthelawsandotherlegaldocumentsgoverningthetreatment of drug addicts. The second study is actually community‐basedmonitoring bypeopletreatedfordrugdependence,anditprovidesinsightintothemannerinwhichthelegalprovisionsforthetreatmentofdrugaddictsarecarriedoutinpracticeinSkopje.This report is the result of an initiative to improve the quality of drug dependence

programmes, undertaken by the NGO Health Options Project Skopje (HOPS), and thecoalitionSexualandHealthRightsofMarginalisedCommunities. The fieldwork was carried out using the methodology known as ‘community‐basedmonitoring’.Themethodused—the inclusionof the community inall thephasesof theproject’sdevelopment—isnew.Akeyelementofthismethodologyisthatrepresentationis based on the results of research carried out to identify the position of the wider                                                            (11)Calculatedaccordingtothemethodofnaturalfamilyplanning,whichused1387796844asthenumberofpeopleaged15–64(averagepopulation(x1.000),in2010was2055,ofwhich67.8%wereaged15–64years)(CentralIntelligenceAgency,2011).(12)V.DimitrievskiandN.Boskova(2012), Improving thequalityof theprogrammes forcuresdrugaddiction inSkopje:assessment of the quality of drug dependence treatment programmeswith a community basedmonitoring by persons treated for drug dependence , HOPS Healthy Options Project, Skopje, Coalition ‘Sexual and health rights ofmarginalisedcommunities’.

 

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stakeholdercommunity.Community‐basedmonitoringistheassessmentoftheattitudesoftherelevantcommunityregardingsomecircumstancesof importanceto thatcommunity.The monitoring is performed for a limited time, and the results are then presented tocompetentorganisations/institutionswitharequestforimprovementintheconditionsofthecommunity(13).Thelegaldocumentsanalysisexploredtheadvantagesofandbarrierstoimprovingthe

qualityofdrugdependencetreatmentprogrammesinSkopje.Thisanalysiswasdoneusingthe results of previously performed fieldwork research (quantitative and qualitative,community‐based)carriedoutbyindividualstreatedfordrugdependenceinSkopje.The fieldworkresearch includedtheCentre for thePreventionandTreatmentofDrug

Abuse in Kisela Voda, including the Unit within the Public Health Institution (PHI)UniversityClinics,Skopje,underthecontrolofthisCentre,andthePHIUniversityClinicforToxicology,Skopje,becausealltheseprogrammesarefinancedbythecountry’sbudgetandassuchitwasfeltthattheyshouldbesubjecttocivilmonitoring. The comparison of the legal documents analysis and the results of the fieldworkresearchprovideadeeperinsightintotheapplicationofthelegislation.It should be borne in mind that the quality of drug dependence treatments in this

documentisviewedsolelyfromtheperspectiveofpatientsofdrugdependencetreatmentprogrammes,andnotfromtheperspectiveofprogrammestaff,andthatthisdocumentwasproducedwith the intentionofassisting innegotiationsbetweendrugusersononeside,and policy creators and implementers on the other, to improve the quality of drugdependencetreatmentprogrammesinSkopje.Alltheprogrammesthatwereanalysedarefinanced,fullyorpartially,withfundsfromthenationalbudget.This document demonstrates the need to respect the legal provisions that guarantee

equal healthcare to all citizens, and consequently to improve the quality of drugdependence treatment programmes in Skopje, based on the needs of people treated fordependenceintheprogrammescoveredbythemonitoring.Community‐basedmonitoringisanessentialcomponentofengagingthecommunityasa

whole in the assessment and supervision of services being delivered through theGovernmentmechanism.Itsobjectivesare:toraisetheawarenesslevelofthecommunityabouttheavailableGovernmenthealthservices;toencouragecommunityparticipationinmonitoring Government health services; to ensure accountability among the serviceproviders to provide the stipulated quality service; to identify gaps in the delivery ofqualityhealthservices.The community‐basedmonitoring fieldworkwas composed of two parts, quantitative

and qualitative. The quantitative part was performed via three separate surveys, usingcitizenreportcards(CRC),compliantwithcommunity‐basedmonitoringmethodology(14).

Themonitoringisperformedforalimitedtime,andtheresultsarethenpresentedtocompetentorganisations/institutionswitharequestforimprovementoftheconditionsofthecommunity (15).

As can be seen in Table 4.1, which shows the research sample per treatmentprogrammesincludedintheCRCs,atotalof182intervieweeswerecoveredwiththeCRCs,                                                            (13)V.Gofman(2010),Communitybasedmonitoring:handbookreportno.21,August,ISBN978‐9979‐9778‐4‐1.(14)ADBandPAC,2007.  (15) Official Gazette of the Former Yugoslav Republic ofMacedonia, 8/12, Programme for Healthcare of PersonswithSubstanceUseDisordersintheFormerYugoslavRepublicofMacedoniafor2012.

 

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ofwhich33.52%(б=61)usedCRC1,34.07%(б=62)usedCRC2,and32.42%(б=59)usedCRC3.

Table4.1.NumberofintervieweespertreatmentprogrammecoveredbyCRCs.

Complementarytothequantitativeresearch,ashortqualitativestudywascarriedoutthatproducedatotalof17researchunits,ofwhich12werein‐depthinterviewsandfivewerefocusgroupdiscussions.Conclusions

Therighttotreatmentfallswithinthegroupofeconomic,socialandculturalhumanrights,asopposedtopoliticalandcivilrights(16),buttherighttotreatmentshouldnotbedeemedaseparateright,becauseitiscloselyconnectedtootherrights,whichfurtheremphasisestheinter‐connectionandinseparabilityofhumanrights(17).

The right to treatment is a constitutional right, guaranteed with theConstitution(18), and is regulated by the Law on Health Protection, which alsoguaranteestimelyandeffectivetreatmentandrehabilitationbyapplyingexpertise,medical measures, activities and procedures to everyone(19). One of the basicprinciples of the Law on the Protection of Patients’ Rights is the accessibility tohealthservicesforallpatientsequally,withoutdiscrimination(20).

  Thedrugdependence treatmentprogrammes inSkopjeare intended,aboveall, totreat opiate/opioid dependent adults. There are no programmes adapted to thetreatmentofopiate/opioiddependentminors,especiallynot for individualsbelow

                                                            (16)KluwerLawInternational(2011),Economic,socialandculturalrights,KluwerLawInternational,AlphenaandenRijn.(17) United Nations (1993)UnitedNationsWorld Conference onHuman Rights, ViennaDeclaration and Programme ofAction,UNdoc.A/CONF.157/23,12July1993,PartI,UnitedNations,Geneva.(18) Official Gazette of the Former Yugoslav Republic of Macedonia, no. 52/1991, Constitution of the Republic ofMacedonia,article39.(19)OfficialGazetteoftheFormerYugoslavRepublicofMacedonia,no.38/1991,46/1993,55/1995,10/2004,84/2005,111/2005,65/2006,5/2007,77/2008,67/2009,88/2010,44/2011and53/2011,LawonHealthProtection,articles2and3.(20)OfficialGazetteoftheFormerYugoslavRepublicofMacedonia,no.82/08и53/2011,LawonProtectionofPatients’Rights,article3paragraph3line1.

 

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theageof16.Therearenoprogrammesforthetreatmentofdrugdependentpeoplewho do not fall into the group of opiates/opioid drugs funded by the country’sbudget.

  Opportunities for access to drug dependence treatment programmes are limited,especiallybecausetheprogrammes’openinghoursareoftenincompatiblewiththehabitsandneedsofpatients,butalsobecausetreatmentprogrammescanbealongwayawayfrompatients’homes,whichcreatesadditionalcosts fortransport.Also,pharmacological therapy is often carried out in locations that do not allow forsufficientconfidentiality,whichcreatesthepotentialfortheidentityofthepatientstoberevealedtothewidercommunity.

Duringbuprenorphinesubstitutiontherapy,thepharmacologicaltherapyisfreeofcharge in the period of induction, which lasts from seven to 10 days, when thepatientpayshospitalcharges.Furtherintothetreatment,fromthefollowingmonthto three months, patients buy buprenorphine with their own funds, with aprescription, and if they do not relapse, after the expiry of this period, thepharmacologicaltherapybecomesfree.

 

Patientsarenotsufficientlyfamiliarwiththeirownrightsandobligationswhenindrugdependencetreatmentprogramme,becausetheydonotlistencarefullytothecompulsoryexplanations theyareprovidedwithat thestartof the treatment,butalsobecausetheydonotreceiveacopyofthetherapycontractthattheymustsigntoentertheprogramme.

  Activities for psychosocial support, working therapy and creative expression areinsufficient or non‐existent, although they would offer opportunities for the re‐socialisationofpatients,andthereisaneedforsuchactivities.

InthedrugdependencetreatmentprogrammesinSkopjethereisnodiscriminationonthebasisofethnical,religious,racialorpoliticalgrounds,butcertainpatientsareprivilegedbecauseofpersonalorfamilyacquaintancesandcontactswithemployeesoftheprogrammes.

  There is no special provision for the treatment of dependence among pregnantwomen and minors, despite the fact that their treatment was proposed in theNationalDrugsStrategy(2006–12).

 

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5.DRUG‐RELATEDTREATMENT:DEMANDANDAVAILABILITY

5.1.Introduction:thegeneralconceptofcollectingtreatmentdataattheEuropeanlevel 

AccordingtotheEMCDDA’sunderstandingofdrugtreatment, informationonthenumberofpeopleenteringtreatmentforadrugproblemprovides insightintogeneraltrendsandcharacteristics of problem drug use; it also offers an indirect perspective on theorganisationanduptakeoftreatmentfacilities. Routinedatacollection isalreadyestablishedand implemented inmanyEuropeancountries following an established European protocol (the treatment demand indicator(TDI)protocol).Thisprotocolprovidesauniformstructure for reportingon thenumberandcharacteristicsofclientsreferredtodrugtreatmentfacilitiesandisbasedonvariousitemsconcerning the typeof treatmentprovidedand thecharacteristicsofclients: socio‐demographicdataanddrugsinformation. TheobjectiveoftheTDIistoincreasethecomparabilityofdatabetweencountriesbyharmonisingnationaloperationaldefinitions.Thecollectionsystemclassifiesclientsbyprimaryandsecondarydrugsused,wheretheprimarydrugisthedrugreportedastheonethat causes the client themost problems, while the secondary drugs are those taken inadditiontotheprimarydrug(atthesametimeoratadifferenttime).

The history of drug treatment and treatmentmonitoring in the Former YugoslavRepublicofMacedonia

Thetreatmentofdrugdependentusersdatesbacktothelate1970sandearly1980s,withtheintroductionofsubstitutiontreatment(methadone).UntilthefirstNationalDrugsStrategywasadopted,thistypeoftreatmentwascentralised.

Inthecourseof2006,intheframeworkoftheprogrammeforBuildingaCoordinativeResponsetoHIV/AIDSPrevention(supportedbytheGlobalFund),theMinistryofHealthopened 10 new services for the treatment and harm reduction of drug abuse, includingMMT,inninecities(21),andoneinthemainprisoninSkopje.

TheseservicesaresupportedbytheMinistryofHealth,MinistryofLabourandSocialPolicy, theCentre forSocialWork, the localcommunityandNGOs.Thisdevelopmenthascreated the foundations for improved service coverage, therapeutic services availabilityand strengthening of institutional capacities. Furthermore, it enabled larger numbers ofprofessionals to be hired, effectively working in multidisciplinary teams at the regionallevel.Inaddition,anewmodelforcontinuousmonitoringandtechnicalsupporttoanswertheneedsofthetargetgroupcouldbeinitiatedatthesametime.

In the framework of the implementation of the National Drugs Strategy (2006–12),furtherdecentralisationandexpansionofthenetworkofservicesfortreatmentandharm                                                            (21)Strumica,Kumanovo,Stip,Ohrid,Gevgelija,Bitola,Veles,KavadarciandTetovo.

 

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reduction of drug abuse, including MMT, took place with the opening of two additionalcentresinSkopje,andtwomoreinprisonfacilities,oneinthecityofBitolaandanotherintheremand(pre‐trial)prisonSkopje,inSkopje.

Treatmentoptionswere furtherexpandedwith the introductionofbuprenorphine in2009. The only institution currently offering treatment with buprenorphine is theUniversity Clinic of Toxicology, Mother Teresa Clinical Centre, Skopje. Buprenorphine isusedfordetoxificationandsubstitutiontreatment.

MethodologicalframeworkofdatacollectionData on inpatient and outpatient facilities providing treatment for drug users are

collected following this general definition of the TDI at the European level. The TDI iswidely recognised as an instrument for collecting information on people enteringtreatment fordruguse.Data collection follows themost recent protocol of theTDI (TDI3.0), which was formally adopted by the EMCDDA in 2012. However, up to now,information has almost exclusively been available on users of opiates (i.e. heroin) insubstitutiontreatment.Reporting at thenational level isbasedonaggregated information from20 treatment

centres(includingsubstitutioncentres,privateclinicsandtreatmentfacilitiesinprisons).Astructuretocollectindividualdataatthenationalleveldidexistinthepast(embeddedintothesystemofnationalhealthstatistics).Although,currently,noelectronicsystemexiststocontinue this detailed data collection, treatment centres are prepared and willing tocooperateinafuturesystem.

In addition to users who start a treatment for their drug use in the reporting year,thereisalargegroupofpeoplewhostayintreatmentforalongperiodoftimeduetothechronicorlong‐termnatureoftheiraddiction(22). Aside from the current limitation (the focus on substitution treatment), themonitoring system is set up and able to provide harmonised and comparable datawithnationalcoverage. Information isavailable forallclients in treatmentat thebeginningofthe year and starting treatment during the year. This report covers data from2012 (12months)andthefirsthalfof2013(sixmonths). Informationprovidedinthisreportisbasedontwodatasources:x Estimates for the total number of clients in treatment are based on information

collected by the Healthcare Programme for People with Addictions in 2012 and2013(23).Thisdatasourceonlyincludesinformationonthetotalnumberofclientsandtheirrespectivediagnoses(andsomeadministrativeinformation).

x Detailedreportingonthecharacteristicsofusersisalmostexclusivelybasedon(paper‐based)TDIquestionnaires sentoutby theNFP.BetweenMayand July2013 theNFPcontactedeveryinstitutionprovidingtreatmentfordrugusers.

                                                            (22)EMCDDA,www.emcdda.europa.eu(23)Governmentof theFormerYugoslavRepublicofMacedonia,Programme forHealthcareofPersonswithSubstanceUseDisordersintheFormerYugoslavRepublicofMacedoniafor2012and2013,OfficialGazetteoftheFormerYugoslavRepublicofMacedonia,no.4/2013.

 

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5.2.Strategy/policy

Eventhoughmarijuanaisthemostabuseddrug,heroinisofgreaterconcernintheillegaldrugsfieldbecauseofusers’high‐riskbehaviour(i.e.thedangerofspreadingofanumberofblood‐borneandsexuallytransmittedinfections,primarilythosecausedbyHIV,hepatitisBvirus(HBV)andhepatitisCvirus(HCV)incasesofintravenousabuse),andtheassociatedhighriskofafataloutcome.

Notwithstandingthisalarmingsituation,thetreatmentoftheseseriousandcomplexsocio‐medicalphenomenawasinrecentyearsmostlylefttomedicalinstitutions,primarilypsychiatricones,andfinancedbyhealthinsurance,yieldingmodestresultsinconditionsoftotalabsenceofsupportfromtheothernecessarysystems.

Within the implementationof theNationalDrugsStrategy2006–12, a systemof carethat includes outpatient treatment, hospital treatment, detoxification and substitutiontreatmentwasdeveloped.Thetherapeuticprogrammesareanintegratedpartofthepublichealthmodelandarecontinuouslymonitoredandevaluated.

The secondNationalDrugsStrategy (2014–20) is in theprocessof preparation. It isexpectedthatthisstrategywilladdresstheneedforcounsellingservicesandtreatmentforother types of addictive controlled substances like marijuana, stimulants and newpsychoactivesubstances,andwillimprovethequalityofthetreatmentsystem.

Nationallawsconnectedwiththecareandtreatmentofdrugaddictionsare:‐LawontheControlofNarcoticDrugsandPsychotropicSubstances(24);‐LawonProtectionofPatients’Rights(25);‐LawonHealthProtection(26);‐LawonHealthInsurance(27).

In2012twonewguidelineswereadopted: theGuidelinesonProvidingHealthcarewhenAdministering Methadone for Opiate Dependence Treatment; and the Guidelines forHealthcareRelatedtoChildrenwithNeonatalWithdrawalSyndrome.

                                                            (24)OfficialGazetteoftheFormerYugoslavRepublicofMacedonia,no.103/2008,LawontheControlofNarcoticDrugsandPsychotropicSubstances.(25)OfficialGazetteoftheFormerYugoslavRepublicofMacedonia,no.82/08and53/2011,LawonProtectionofPatients’Rights.(26)OfficialGazetteoftheFormerYugoslavRepublicofMacedonia,no.43from29March2012,LawonHealthProtection.(27)OfficialGazetteoftheFormerYugoslavRepublicofMacedonia,no.19/2011,LawonHealthInsurance.

 

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5.2.1.GuidelinesonProvidingHealthcarewhenAdministeringMethadoneforOpiateDependenceTreatment(28)These Guidelines, adopted in 2012, include information not only about pharmacologicaltreatmentbutalsotheneedforpsychologicalandsocialinterventions.

The Guidelines provide a broad overview of the basic principles of OST, which aremainlyorientedalongtheNIDAprinciplesoftreatmentandWHOguidelinesforprovisionof OST. They also contain a substantial amount of background information on theinteractionofmethadonewithothersubstancesandinformationaboutdifferenttreatmentregimes.Thekeyelementsare:concretesuggestionsformedicalexaminations;criteriaforinclusiononthemethadoneprogramme;therapeuticplanandpurpose;andotherpracticalissues,includingdosagesandtreatmentschemesofhowOSTshouldbecarriedout.

5.2.2.GuidelineonProvidingHealthcarewhenAdministeringMethadoneforOpiateDependenceTreatment(29)Neonatal abstinence syndrome (NAS) is a groupof problems thatoccur in anewborn

baby who was exposed to addictive illegal or prescription drugs while in the mother’swomb.Babiesofmotherswhodrinkduringpregnancymayhaveasimilarcondition(30).These guidelines, adopted in 2012, contain all the necessary information and

recommendations of how the medical system should deal with children (and theirmothers)exposedtosubstanceuseduringpregnancy.5.3.Thetreatmentsystem 

Asmentionedabove,theNationalDrugsStrategy2006–12addressedforthefirsttimetheneed foramulti‐facetedapproach to treatingdrugusers, includingoutpatient treatment,detoxificationandOST.

In accordancewith theLaw forHealthProtection, theCentres for theTreatment andHarmReductionofDrugAddictionshouldbepartofthehospitals,withaminimumstaffofonemedical doctor (GP), one psychiatrist and onenurse, but these are only available inlarge hospitals. Drug treatment is available within the framework of the public healthnational service network, making the public sector the leading actor in drug‐relatedmedicallyassistedtreatment.Themainfunderofdrug‐relatedtreatmentistheMinistryofHealth,because thisdrug treatment isalsoavailable forpeoplewithout social insurance.There are few private psychiatric clinics that treat drug addicts, and the funds for thetreatmentarepartiallyorentirelyprovidedbythepatients.Theprofessionalsengagedin

                                                            (28)OfficialGazetteoftheFormerYugoslavRepublicofMacedonia,no.36/2012,GuidelineonProvidingHealthcarewhenAdministeringMethadoneforOpiateDependenceTreatment.(29)OfficialGazetteof theRepublicofMacedonia,no.36/2012,GuidelineonProvidingHealthcarewhenAdministeringMethadoneforOpiateDependenceTreatment.(30)JanssonLM,VelezM.Neonatalabstinencesyndrome.CurrOpinPediatr.2012Jan5.[Epubaheadofprint] 

 

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treatment are psychiatrists, general practitioners (GPs), nurses, pharmacists, socialworkersandpsychologists.Thereisnospecialtyinaddictionmedicine.

Themajorityofdrugusersreceiving treatmentareoutpatients, receivingsubstitutiontreatment, psychosocial interventions, individual or group counselling and psychosocialtherapy. However, it remains unclear to what extent other interventions apart frompharmacologicaltreatmentareavailable.

Treatment is available in three social care centres, 10 centres and three in prisonsettingsforthetreatmentofdrugusers(MMT),onetherapeuticcommunity,twohospitalsand one hospital with capacity for detoxification. Methadone was introduced as a drugsubstitute in 1992, and it remains the main substance prescribed for substitutiontreatment.Buprenorphine, introducedin2009, isusedfordetoxificationandsubstitutiontreatment. Nearly 1250 drug users are involved in programmes for MMT and receivemethadonedailyorweekly.TheGovernmentadoptstheprogrammeeachyearaspartofitshealthcareprovisionforpeoplewithaddiction.5.3.1.Thecharacteristicsoftreatedclients5.3.1.1.PatientsinMMTinpublichealthfacilitiesin2013

Table5.1.NumberofpatientsintreatmentfacilitiesforF11.2in2013.Drugscategory(secondarydrug)

2013 TOTAL

15–19 20–34 35–44 45–54 55–64M F Total M F Tota

lM F Total M F Tota

lM F Total

F11opiates,heroin

1 1 542 70

612 248 20

268 35

1 36 2 2 919

F12cannabis 2 2 49 8 57 25 25 84F13sedatives‐hypnotics

59 10

69 29 29 1 1 99

F14cocaine 1 1 1F15stimulants 1 1 1F16hallucinogens

3 3 2 1 3 6

F19polydruguse 14 1 15 11 1 12 3 3 1 1 31Total 3 3 668 8

9757 315 2

2337 3

92 38 3 0 3 1141

Therewere1141patientsintreatmentfacilitiesunderICD‐10codeF11.2(31)in2013.AllwereopiateaddictsonMMT,but theyusecannabis,benzodiazepines,etc.asasecondarydrug.                                                            (31)ICD‐10–InternationalClassificationofDiseases,F11.2–Drugdependence(opiates).

 

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Figure5.1NumberofpatientsintreatmentfacilitiesforF11.2in2013.

Source:CentresforPublicHealth

5.3.1.2.Pharmacologicallyassistedtreatment:patientsonopioidsubstitutiontreatment(32)Anothersourceofinformationinadditiontoroutinedatacollectioncomesfromarecent

studypublishedbyPetrusevskaet al. (2014)exploring the characteristicsofOSTclients.Theaimofthequantitativeanalyticalcross‐sectionalstudy,whichwasconductedbetweenSeptember andDecember 2013,was to analyse national data fromOSTmedical recordsandtocompareitwithdatafromEUcountries.MedicalrecordswereanalysedforallpatientsonOSTatthenationallevelduring2012.

DataforOSTpatientsonMMTwereobtainedfromall13publictreatmentfacilitieslocatedin10cities, threeprivatecentres inthecapitalofSkopjeandthreeprisons.Data forOSTpatients on buprenorphinewere obtained from the Clinic for Toxicology,Mother TeresaClinicalCentre,StCyrilandMethodiusUniversityinSkopje.The data collected in the country was compared with data from 10 EU countries

(Austria, Denmark, France, Germany, Greece, Italy, Norway, Portugal, Sweden and theUnitedKingdom).ThesurveywasbasedontheitemsdefinedintheTDIProtocol3.0fromtheEMCDDA(33).

National legislationsetup inclusioncriteria forMMTof18yearofageandabove. Inspecialcircumstances,youngerpeoplecanbeincludedinMMT.Intheperiodanalysed,fivepeople were receiving treatment in the age category 15–19, of which one receivedtreatment inapubliccentre,oneinaprivatecentreandthree inprisons.Thisbringsthe                                                            (32)T,Petrushevska,V.V.Stefanovska(2014),‘PatientsonopioidsubstitutiontreatmentintheFormerYugoslavRepublicofMacedonia:whatdotreatmentdemanddatatellus?’MacedonianJournalofMedicalScience,manuscriptIDMJMS‐2014‐0575.(33) EMCDDA (2012),Treatmentdemand indicator (TDI) standardprotocol3.0.Guidelines for reportingdata onpeopleenteringdrugtreatmentinEuropeancountries,EMCDDA,Lisbon,ISBN978‐92‐9168‐507‐3,doi:10.2810/5285. 

 

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totalnumberofOSTpatients to1671.Data for the fiveminorshavebeenexcluded fromthe analyses. The total number of OST patients in all available opioid substitutiontreatment facilitieswas1857,ofwhich10%wereonbuprenorphineand90%wereonmethadone. Of this total, 1355were receivingOST (MMT and buprenorphine) in publiccentres.BuprenorphineisstillexclusivelyprovidedintheUniversityClinicofToxicology,atthetertiaryhealthcarelevel.

Theratioofmaletofemaleheroinclientswas11:1,or162femaleclients(9%).Whileonly10%ofOSTclientsweretreatedwithbuprenorphine,90%wereonmethadone;130(80%) receivedMMT in public centres. Of all OST patients, 54%onMMT and 65%onbuprenorphinewereaged20–34.

Table5.2.OSTpatientsonMMT. 20–34 35‐40 41–55 Total %

M F Total M F Total M F Total Publiccentres N 510 63 573 353 50 403 176 17 193 1169 70%

% 43.6 5.4 49 30 4 34.5 15 1.5 16.5 100%Privatecentres

N 94 15 109 15 3 18 11 2 13 140 8.4%% 67 11 77 11 2 13 8 1.4 9 100%

Prisons N 207 12 219 116 0 116 22 0 22 357 22%% 57.9 3 61 32 0 32 6 0 6 100%

TOTAL N 811 90 901 484 53 537 209 19 228 1666 100%% 48 5.3 54 29 3 32 12 1 14 100%

Source(T.Petrushevska,IDisMJMS‐2014‐0575.2014)

Table5.3.PatientsreceivingOSTwithbuprenorphinemaintenance.Age

Ethnicity 20‐34 35‐40 41‐55 TOTALM F Total M F Total M F Total

National N 71 17 88 34 0 34 14 0 14 136% 52 12.5 65 25 0 25 10 0 10 73

Albanian N 30 0 30 13 0 13 4 0 4 4725% 64 0 64 28 0 28 8.5 0 8.5

Roma N 2 0 2 1 0 1 0 0 0 3% 67 0 67 33 0 33 0 0 0 1.6

TOTAL N 103 17 120 14 0 48 18 0 18 186100%% 55 9 65 8 0 26 10 0 10

In10of12cities,thelargestgroupofOSTpatientswereaged20–34.Itwasevidentthatveryyoungpeoplewereheroinaddictsandwerealreadyreceiving

MMT. It was found that patients currently on drug treatment started injecting heroinbetweentheagesof14–22,andtheaverageageoffirstheroinusewas18.

Analysis of level of education showed that: 105 patients (9%) were without basiceducation;368(31%)wereeducatedtotheprimary level;686(59%)wereeducatedtothesecondarylevel(highschool);and11(1%)hadreceivedhighereducation.

Living status data analysis of 1314 OST patients (except OST patients from three

prisons)showedthat:57(4.3%)livedalone;854(65%)livedwithfamily;326(24.8%)

 

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lived with a partner; 13 (1%) lived with friends; 4 (0.3%) lived in an institution (notdetention); 60 (4.6%) were in prison. A total of 83% (1090) of the patients had apermanentresidence.

Patients in public OST who had children: 487 patients (36%) had children; 337patients(69%)werelivingwiththeirchildren;150patients(31%)werenotlivingwiththeirchildren;868patients(58.3%)hadnochildren.

LabourstatusofpatientsonOSTinpublichealthinstitutions:188(14%)hadapart‐time job;157(12%)hadpermanentemployment;10(1%)werestudents;860(63.4%)werenotinemployment;141(10%)werereceivingsocialsupport.

5.3.1.3.TreatmentinprisonsThestudybyPetrusevskaetal.alsocontainsinformationonOSTtreatmentinprisons.

They found that all OST patients on MMT in prison were from three prisons: 190 OSTpatients(65%ofa totalnumberof290prisoners)wereintheremand(pre‐trial)prison‘Skopje’; 139 (11%of 1306 prisoners)were in IdrizovoPrison, Skopje; and38were inBitolaPrison(56%of69prisoners).TherearethreeMMTcentresinprisons:inthepre‐trialprison‘Skopje’,intheregularIdrizovoPrison,SkopjeandinBitolaPrison.Other prisoners (N=57)were receivingMMT from community treatment centres. The

programmes that provided prisoners in prisonwith OST also arranged their transfer toappropriatecommunitytreatmentcentresfollowingrelease.ThetotalnumberofprisonersinOSTwas 420. In terms of ethnicity, in all treatment facilitieswithMMT, 66.6%werenationals,24%wereAlbanian,6%wereRomaand3.6%wereclassedas‘other’.

UseofbenzodiazepinesassecondarydrugsAll publicMMT centres recorded benzodiazepines (BZD) use, except oneMMT centre inSkopje, and one that is collecting partial medical data for BZD. Analysis of public MMTfacilitiesrefersto831patients,ofwhich608useBZD(73%).Table5.4.PatientsreceivingOSTwithdiagnosedbenzodiazepinesuse(ICD‐10,F13). Age

20–34 35–40 41–55 TTOOTTAALL TToottaallNNoo..OOSSTTppaattiieennttss

MM FF TToottaall MM FF TToottaall MM FF TToottaall PUBLICOST

NN 289 22 311 205 13 218 72 7 79 608 831%% 47 4 51 34 2 36 12 1 13 100 73

PRIVATEOST NN 76 11 87 13 3 16 7 2 9 113 141%% 67 10 77 11.5 3 14 6 1.7 8 100 80

TOTAL

NN 365 33 398 218 16 234 79 9 88 720 972%% 51 4.5 55 30 2 32.5 11 1 12 74

Source(T.Petrushevska,IDisMJMS‐2014‐0575.2014)

 

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Analysisshowedthat:a)Therewasadifference inBZDusebetweencities.Thepercentageofpatientsusing

BZDwas:93% inOhrid (107of115patientsonOST);91% inVeles (42of46onOST);81% in Skopje (163 of 201 patients on OST for which there are medical records forsecondarydruguse); 79% in Strumica (58 of 73 onOST); 69% inTetovo (54of 94 onOST); 64% in Bitola (59 of 92 on OST); 56% in Kavadarci (19 of 37 on OST); 56% inGevgelija(34of61onOST);and53%inKumanovo.b)Therewasadifference inBZDusebyage:41%(398)of thepatientswere in theagegroup20–34.c)TherewasadifferenceinBZDusebygender:of662patients,92%weremaleand8%werefemale.Comparison of national datawith data from 10 EU countries (Austria,Denmark, France,Germany,Greece,Italy,Norway,Portugal,SwedenandtheUnitedKingdom)

In theEU the ratio ofmale to femaleheroin treatment clients is4:1(34).At nationallevel,theratioofmaletofemaleheroinclientsis11:1.

Astudyfoundthat femalesinIsraelweremore likelytoenterMMTatayoungeragethanmales,withtwiceasmanymalesasfemalesbeingadmittedfortreatmentinthe18–30agegroup(35).Thesituationissimilarinthecountry,where1.6%offemalepatientsareintreatment in the age group 20–34.Male patientsmake up 89%of all patients,while ananalysis carried out in 10 EU countries using the European Quality Audit of OpioidTreatment(EQUATOR(36)),designedtoprovideanoverviewofthecurrentstateofopioidtreatmentprovisioninEurope,foundthat74.6%ofpatientsweremale.Thisdistributionwas also seen in individual countries, and there were consistently more male patients(range66–82%)thanfemale:79%ofopioiddependentpatientsobservedbytheEMCDDA(datafromcountries(37)takingpartinEQUATOR)weremale(38);84%ofOSTpatientsinthePROTEUSstudyinSpainweremale(39);73%ofOSTpatientsintheDTORSstudyintheUnitedKingdomweremale(40);and68%ofpatientsintheGermanPREMOSstudyweremale(41).

                                                            

(34)EMCDDA (2013),Perspectivesondrugs: trends inheroinuse inEurope—whatdo treatmentdemanddata tellus?,EMCDDA,Lisbon.(35)M.Schiff,S.Levit,R.C.Moreno(2007), ‘RetentionandillicitdruguseamongmethadonepatientsinIsrael:agendercomparison’,AddictiveBehaviors32,pp.2108–2119(http://www.ncbi.nlm.nih.gov/pubmed/17335982).(36) G. Fischer and H. Stöver (2012), ‘Assessing the current state of opioid‐dependence treatment across Europe:methodology of the European Quality Audit of Opioid Treatment (EQUATOR) project’ Heroin Addiction and RelatedClinicalProblems14,pp.5–70.(37) G. Fischer and H. Stöver (2012), ‘Assessing the current state of opioid‐dependence treatment across Europe:methodology of the European Quality Audit of Opioid Treatment (EQUATOR) project’ Heroin Addiction and RelatedClinicalProblems14,pp.5–70.(38) J.GoulãoandH.Stöver (2012), ‘Theprofileof patients,out‐of‐treatmentusers and treatingphysicians involved inopioidmaintenancetreatmentinEurope’,HeroinAddictionandRelatedClinicalProblems14(4),pp.7–22.(39) C. Roncero, on behalf of thePROTEUS Study investigators (2011), ‘Therapeuticmanagement and comorbidities inopiate‐dependentpatientsundergoingareplacementtherapyprogrammeinSpain:thePROTEUSstudy’,HeroinAddictionandRelatedClinicalProblems13,pp.5–16.  (40)A.Jonesetal.(2007),TheDrugTreatmentOutcomesResearchStudy(DTORS):researchreport3(www.dtors.org.uk).(41)H.U.Wittchen,G.BühringerandJ.Rehm(2011),‘ErgebnisseundSchlussfolgerungenderPremos‐Studie’(‘Predictors,moderatorsandoutcomeofsubstitutiontreatment’),SuchtmedizininForschungundPraxis13,pp.199–299.

 

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TheaverageageofpatientsacrossEuropewas36.5,rangingfromanaverageof31.9inAustria to 43.8 in Denmark(42). In the same way, the mean age of patients enteringtreatment for opioid dependence in the EMCDDA dataset(43) was 34.1; the mean agereportedintheGermanCOBRA(44)studywas34.8and inthePREMOS(45)study35; thePROTEUS(46) study in Spain reported a mean age of 39; in the UK DTORS study(47),patientsonOSTwereagedbetween25and44(45%wereaged25–34;27%were35–44;7%were≥45).AmongOSTpatienttreatedinpublichealthfacilitiesin2012,dataforagedistributionweresimilartothefindingsoftheUKstudy,with52%ofpatientsaged20–34;33%aged41–55;and16%aged41–55,whilethereisevidencethatveryyoungpeopleareheroinaddictsandarealreadyonmethadonetreatment.

Itshouldbenotedthattheageatwhichpatientswhowerereceivingtreatmentin2012firsttookheroinwas14–22.ThemeanageoffirstheroinuseintheEUis22yearsand,incomparison,amongcitizensitis18years.

With regard to level of education, a comparison between national data and datapresented instudiesmentionedbelowshowedthattheproportionofnationalpatientsinOSTwhohadnotattendedhighschool(37%)issimilartodatafromSweden(35.5%)andtheUnitedKingdom(39.5%),butlowerthantheEUaverage(42.3%).TheproportionofpatientsinOSTwhowereeducatedtohighschoollevel(62%)isequivalenttothefigurefromSpain(62.4%),andhigherthantheEUaverage(30.9%).TheproportionofpatientsinOSTwhowere educated to degree (higher education) level (1%) is the same as datafromtheUnitedKingdom(1.2%),whichishigherthantheEUaverage(0.3%).It has been estimated that up to one‐third of all heroin addicts pass through a

correctional facility each year(48). The chronic nature of untreated heroin dependencemeans that imprisonment is usually repeated; studies in the United States and Francefoundthathalfofheroinusersreleasedfromprisonreturnedwithinsixmonths(49,50).Polydrug use is predominant among drug users who wish to reduce the unwanted

effectsofdrugtakingortoenhancethedesiredones(51,52,53).Thesubstancesdetectedmost                                                            (42) J.GoulãoandH.Stöver (2012), ‘Theprofileof patients,out‐of‐treatmentusers and treatingphysicians involved inopioidmaintenancetreatmentinEurope’,HeroinAddictionandRelatedClinicalProblems14(4),pp.7–22.(43)EMCDDA(www.emcdda.europa.eu).(44) H.U. Wittchen et al. (2008), ‘Feasibility and outcome of substitution treatment of heroin‐dependent patients inspecializedsubstitutioncentresandprimarycarefacilities inGermany:anaturalisticstudyin2694patients’,DrugandAlcoholDependence95,pp.245–257.(45)H.U.Wittchen,G.BühringerandJ.Rehm(2011),‘ErgebnisseundSchlussfolgerungenderPremos‐Studie’(‘Predictors,moderatorsandoutcomeofsubstitutiontreatment’),SuchtmedizininForschungundPraxis13,pp.199–299.(46) C. Roncero, on behalf of thePROTEUS Study investigators (2011), ‘Therapeuticmanagement and comorbidities inopiate‐dependentpatientsundergoingareplacementtherapyprogrammeinSpain:thePROTEUSstudy’,HeroinAddictionandRelatedClinicalProblems13,pp.5–16.(47)A.Jonesetal.(2007),TheDrugTreatmentOutcomesResearchStudy(DTORS):researchreport3(www.dtors.org.uk).(48)A.E.Boutwelletal.(2007),‘Arrestedonheroin:anationalopportunity’,JournalofOpioidManagement3,pp.328–332.(49)J.N.Marzoetal.(2009),‘Maintenancetherapyand3‐yearoutcomeofopioiddependentprisoners:aprospectivestudyinFrance(2003–2006)’,Addiction104,pp.1233–1240.(50)G.P.McMillan,S.LaphamandM.Lackey(2008),‘Theeffectofajailmethadonemaintenancetherapy(MMT)programoninmaterecidivism’,Addiction103,pp.2017–2023. (51)G.Hunt,K.Evans,M.MoloneyandN.Bailey(2009) ‘Combiningdifferentsubstances in thedancescene:enhancingpleasure,managingriskandtimingeffects’,JournalofDrugIssues39,pp.495–522.(52)S.E.LankenauandM.C.Clatts(2005),‘PatternsofpolydruguseamongketamineinjectorsinNewYorkCity’,SubstanceUseandMisuse40,pp.1381–1397.(53)H.Klein,K.W.ElifsonandC.E.Sterk(2009), ‘Youngadultecstasyusers’enhancementof theeffectsof theirecstasyuse’,JournalofPsychoactiveDrugs41,pp.113–120.

 

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often were combinations of morphine, benzodiazepine, methadone and stimulants. Intermsofpolydruguse,theuseofbenzodiazepinesrangedbetween11%and70%amongsubstitutiontreatmentclients(54).BenzodiazepineswerewidelyusedbyheroindependentindividualsandbypatientsinOST(55).Thishighlevelofusemaybeinresponsetothehighincidenceofpsychiatricco‐morbidityinthispopulation(56).BenzodiazepineusebyMMTpatientsisassociatedwithamorecomplexclinicalpicture

andmay negatively influence treatment outcomes(57). Although several studies indicatethat rates of non‐medical prescription drug use are higher among women than men,particularlyfornarcoticanalgesicsandtranquilisers(58),otherstudiesreportequivalentorhigherratesamongmen(59).There have been case reports of deaths apparently associated with injections of

buprenorphine combinedwith benzodiazepines(60),which is the reasonwhy physiciansareverycautiousabouttheuseofthesetwodrugsinconjunction.

ConclusionsVarious treatment options are available for opioid addicts. People in prison receive thesame level of healthcare as those in the community. Demographic profiles appearedrelatively consistent across the country, with differences in themean age of patients intreatment;namely,whileinthecapitalcityofSkopjethepredominantagegroupwas35–40, in the other towns and cities patients were aged 20–34. It should be noted that inprivateOSTpsychiatricclinics,despitethefactthattheyarealllocatedinSkopje,theageofpatients was 20–34. The same situation was found among prison patients, where 62%wereaged20–34. It is important to strengthenpreventivemeasures, to raise awarenessandincreasethe levelof informationwithyoungerpeopleabouttherisksofdrugtaking.TheratioofmaletofemalepatientsishigherthattheEUaverage,andthereasonsforthiswarrant further exploration. There is correlation between a low level of education andwhenheroinabusestarted.BenzodiazepineuseamongMMTpatientswascommon.

Thisveryimportantandcomprehensiveanalysisofpeoplewithdrugaddictionscanlead to successful prevention and treatment responses. Although the treatment networkfor drug addiction is quite developed, there is a perceived need for further capacitybuildingandanincreasethequalityofmedicalcare.                                                            (54)G. Fischer et al. (2011),Thenon‐medicaluseofprescriptiondrugs:policydirection issues, UnitedNationsOffice onDrugsandcrime,NewYork.(55)N.Lint‐erisetal.(2007),‘Pharmacodynamicsofdiazepamco‐administeredwithmethadoneorbuprenorphineunderhighdoseconditionsinopioiddependentpatients’,DrugandAlcoholDependence91,pp.187–194.(56) D. Kandel, F.Y. Huang and M. Davies (2001), ‘Comorbidity between patterns of substance use dependence andpsychiatricsyndromes’,DrugandAlcoholDependence64,pp.233–241.(57)B.Brandsetal.(2008),‘Theimpactofbenzodiazepineuseonmethadonemaintenancetreatmentoutcomes’,JournalofAddictiveDiseases27(3),pp.37–48,doi:10.1080/10550880802122620.(58)L.Simoni‐Wastila,G.RitterandG.Strickler(2004),‘Genderandotherfactorsassociatedwiththenonmedicaluseofabusable prescription drugs’, Substance Use and Misuse 39(1), pp. 1–23(http://www.ncbi.nlm.nih.gov/pubmed/15002942).(59)C.Blancoetal.(2007),‘Changesintheprevalenceofnon‐medicalprescriptiondruguseanddrugusedisordersintheUnitedStates’,DurgandAlcoholDependence90(2–3),pp.252–260(http://www.ncbi.nlm.nih.gov/pubmed/17513069).(60)J.M.Gaulieretal.(2000),‘Fatalintoxicationfollowingself‐administrationofamassivedoseofbuprenorphine’,JournalofForensicSciences45(1),pp.226–228(http://www.ncbi.nlm.nih.gov/pubmed/10641946).

 

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5.3.2.TherapeuticcommunitiesTheonlytherapeuticcommunityinthecountryisPokrov,closetothecityofStrumica.It

is a joint project between the Orthodox Church diocese of Strumica and the NGO Izbor.MostofthefundsfortheprojectweredonatedbytheSwissAgencyforDevelopment(SDC),theMunicipalityofStrumica,theOrthodoxChurchdioceseofStrumica,andotherpartnersfromthelocalbusinesssector.ThewholeprocesswasledandimplementedbytheCentreforInstitutionalDevelopment(CIR).The duration of the programme is 12 to 18 months, and it consists of the following

stages: adaptation; intensive treatment (psychological awareness, personal development,socialisation);re‐socialisation;andreintegration(socialnetworktherapy).The community aims to provide high‐quality services and complementary and

accessible care for addicts. It provides accommodation and food, basic healthcare andmentalhealthobservation.Theprogrammeincludes teachingskills, training inHIV/AIDSpreventionandotherservicescrucialforrehabilitationandsocialreintegration.Itsclientsalso participate in working activities. Courses/lectures and sporting activities areorganisedforpatients.Thecommunityemploysarangeofprofessionalstaff(psychologists,socialworkers,therapistsandotherprofessionals).The therapeutic community model is based on modern methods of withdrawal from

alcohol, drugs and gambling, featuring an integrated approach with professionalpsychotherapy: cognitive behavioural therapy (CBT), eyemovement desensitisation andreprocessing (EMDR) (trauma psychotherapy), systemic family psychotherapy,psychodramaandthemethodoftherapeuticcommunity.

5.3.3.Rehabilitationservices

Therearetworehabilitationservices(inOhridandinKumanovo)linkedtotreatment.TheyworkinclosecollaborationwiththeCentresfortheTreatmentandHarmReductionof Drug Addiction. Rehabilitation and re‐socialisation of drug users and their families isprovided through a variety of individual and group activities: counselling, information,social intervention, psychological intervention and testing, motivation interview, grouptherapy, psycho‐educative groups, therapeutic community, creative and occupationtherapyandcomputerskillsworkshops.

Therearenosocialservicesprogrammesthatprovidedruguserswithhousing,buttheMinistryofLabourandSocialPolicyandthesocialcentreshavethecompetencetoinitiatesocialintegrationofdrugusersinanumberofareas(housing,parental,vocationalservices,etc.).

 

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6.HEALTHCORRELATESANDCONSEQUENCES

6.1.Reportonthecurrentstateofplayofthe2003CouncilRecommendationonthepreventionandreductionofhealth‐relatedharmassociatedwithdrugdependence,intheEUandcandidatecountries,CountryProfiles,2013 

A report was produced under the Health Programme (2008–13) in the frame of acontract with the Executive Agency for Health and Consumers acting on behalf of theEuropean Commission. The report is the result of thework of experts from GesundheitÖsterreichForschungsundPlanungsgesellschaftmbH(GÖFPGmbH)andSOGETI,inclosecollaboration with the Executive Agency for Health and Consumers, the EMCDDA, DGSANCO,andDGJUST.The report presents an updated overview of the implementation of the Council

Recommendation in theEUcountriesand candidate countries, includingcountryprofilesandanalysesofregionalandEUepidemiologicaltrends.Thestudyalsoassessestheaccesstoandcoverageofharmreductionmeasuresbasedontheanswerstoapolicysurvey.Inorder toprovideahigh levelofhealthprotection, theFormerYugoslavRepublicof

Macedoniaidentifiedthepreventionofdrugdependenceandthereductionofrelatedrisksas a public health objective, and developed and implemented comprehensive strategiesaccordingly. Opioid substitution treatment and specialised needle and syringe exchangeprogrammes(NSP)topreventriskbehaviour(e.g.needlesharing)relatedtodrug‐relatedinfectiousdiseases(DRID)(e.g.HIV,hepatitis)havebeenproventobeeffectivebyarangeof high‐quality studies. The broad range of benefits from OST (including a reduction inneedle‐sharingandinjectingdruguse)hasalsobeenobservedinprisons.WithintheNationalDrugsStrategy2006–12,thefollowinggeneralobjectivesarestated:

to maintain a high level of health protection, well‐being and social cohesion bypreventingandreducingdruguse,dependenceanddrug‐relatedharms;

toensureahighlevelofsecurityforthegeneralpublicbypreventingdrug‐relatedcrime—includingactionsagainstdrugproduction,cross‐bordertraffickingofdrugsanddiversionofprecursors.

All EU Member States, Croatia, Montenegro and the Former Yugoslav Republic ofMacedoniahaveadopted(publichealth)policyobjectivesthataimtopreventandreducethehealth‐relatedharmcausedbydrugdependence(61).

                                                            (61)M.Busch,A.Grabenhofer‐Eggerth,M.WeiglandC.Wirl(2013),Reportonthecurrentstateofplayofthe2003CouncilRecommendationonthepreventionandreductionofhealth‐relatedharm,associatedwithdrugdependence, intheEUandcandidate countries, Gesundheit Österreich Forschungs‐ undPlanungsGmbH, Vienna,April, on behalf of the EuropeanCommission. 

 

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SummaryoffindingsintheCountryProfile:Informationandcounsellingservicesfordrugusersrelatedtoharmreductioniswidelyavailable,andtherehasbeenasignificantincreasesince2003.Informationmeasurestargetedatfamiliesandcommunitiesrelatedtoharmreductionarewidelyavailable.ManyseminarsandworkinggroupswereorganisedbytheInter‐ministerialCommissionforNarcoticDrugstogetherwithNGOsandsupportedbytheEUandWHO.Outreachworktargetedatdrugusersiswidelyavailable,andhasbeensubstantially increased. There are four general aims of drugs outreachwork: to identifyand contact hidden populations; to refermembers of these populations to existing careservices; to initiate activities aimed at prevention and at demand reduction; and topromotesafersexandsaferdruguse.Theseactivitiesarecarriedoutby13NGOsforharmreduction, which are financially supported by a Global Fund project that aims to tackleHIV/AIDS and tuberculosis. Peer involvement in outreachwork is available to a limitedextend only, but there has been an increase since 2003. Networking and cooperationbetweenagencies involved inoutreachwork iscommon,andhassubstantially increased.Drug‐relatedtreatmentisavailablenationwidewithintheframeworkofthenationalpublichealthnetwork.Medicallyassistedtreatmentisprovidedmainlybythepublicsector,eitherinhospitalsorinaddictiontreatmentcentres,butalsobythreeprivatepsychiatricservices.Thetreatmentsystemprovidesoutpatientandinpatienttreatment,detoxificationandOST(asmaintenance treatment).Detoxification treatment andpsychosocial interventions areprovided in both inpatient and outpatient settings, while OST, individual or groupcounsellingandsocialandpsychotherapyareavailableinoutpatientservicesonly.Methadone, themain substance used for OST, has been available since 1992. Around

1232clientsreceiveMMT.Buprenorphinehasbeenavailablesince2010fordetoxificationas well as for OST. Measures to prevent the diversion of substitution substances are inplace.In 2012 MMT programmes were available in all prisons. HBV vaccination and

prophylacticmeasures againstHIV,HBV andHCV, tuberculosis and sexually transmitteddiseasesforinjectingdrugusers,andscreeningiswidelyavailabletoinjectingdrugusersand their immediate social networks for HIV, HBV, HCV, tuberculosis and sexuallytransmitted diseases. Medical treatment of HIV/AIDS for injecting drug users is widelyavailable; medical treatment of HCV, tuberculosis and sexually transmitted diseases iswidely available. There has been a substantial increase in thesemeasures since 2003. Amajor achievement since 2003 is that HBV vaccinations have been integrated into thestandardpackageof immunisation.Fifteenneedleandsyringeprogrammesare availableandareimplementedbylocalNGOs.In2008theywereincontactwith1615clients.Elevencitieshavehighcoverage,60%ofallNGOsofferneedleandsyringeexchangeprogrammes(62).Emergencyservices,whichareadequatelypreparedtodealwithdrugoverdoses,arewidely available. There is full integration between health services, social care andspecialised risk reduction, with a significant increase since 2003. A major achievementsince 2003 is that, in addition to treatment centres formethadone substitution therapy,there are now three centres for the re‐socialisation and social integration of drugdependentpersonsandonetherapeuticcommunity.

                                                            (62)AccessandcoverageofneedleandsyringeprogrammesinCentralandEasternEurope,WHORegionalOfficeEurope;CEEHRN–Vilnius,Lithuania 

 

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Professional training on the reduction of health‐related risks associated with drugdependenceisextensivelyavailable,andtherehasbeenabigincrease.Scientificevidenceis used as the basis for selecting interventions to a large extent, and there has been asubstantialincreasesince2003.Qualitycriteriaarewidelyusedinevaluations,andtherehasbeena substantial increase.Standardiseddatacollection is routinelyused,and therehas been a substantial increase since 2003. CARDS (Community assistance forreconstruction, development and stabilisation) and Instrument for Pre‐AccessionAssistanceprojectswerethemaininitiatorsofestablishingaNFPforcooperationwiththeEMCDDAandtosetupindicators,anetworkofinstitutionsandtoimplementstandardiseddatacollection. In2011anevaluationwascarriedoutbyaworkinggroupof15individuals,composed of representatives of the Office of the Global Fund for HIV/AIDS in Skopje,UNICEF, the JointUnitedNationsProgrammeonHIV/AIDS,NGOs,andrepresentativesoftheMinistriesofEducation,LabourandSocialPolicy,andHealth.Themethodologyofthesurveyconsistedofinterviewswithaquestionnaire,withtheoptionofselectingmorethanone answer. All methadone centres are evaluated using questionnaires for staff andmethadone users. A total of 276 questionnaires were filled out, of which 224 werecompleted by methadone users in methadone centres and 52 by staff at methadonecentres. In the methadone centre in Idrizovo Prison, 51 inmates who were methadoneusersandfourstaffatthecentrecompletedquestionnaires.Professionalshaveaconsiderablenumberofopportunities forexchangingprogramme

results, skillsandexperienceat theEuropean level,andtherehasbeenastrong increasesince2003.TheEMCDDAandtheIPAProjectareveryimportantpartnersoftheNFPandall stakeholders. Opportunities for partnership can be increased by study visits andparticipationinworkshops,conferencesandforumsorganisedattheEUlevelforparticularareasof interest.MembershipoftheEuropeanUnionisthehigheststrategic interestandpriority of the Government. All Council Recommendations and Suggestions areimplementedbytherelevantinstitutions.Institutionsandprofessionalshaveworkedhard,showing commitment and adherence to standard practices established in the EU, tostrengthen capacities in the system for the treatment and harm reduction of drugaddiction.WehopethatEUsupportwillcontinueintheforthcomingperiod.

 

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Figure6.1.CoverageofharmreductionmeasuresinEUcandidatecountries.

Notes:1.DRID=drug‐relatedinfectiousdiseases,OST=opioidsubstitutiontreatment.2. Data refer to: Austria, Belgium, Bulgaria, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France, Germany,Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal, Romania,Slovakia,Slovenia,Spain,Sweden,theUnitedKingdom,Croatia,theFormerYugoslavRepublicofMacedonia,Montenegro,Iceland,Turkey.Coverage:1=notavailable,2=rare,3=limited,4=extensive,5=fullcoverageSource:GÖFP,policymakersurvey;graphicrepresentation:GÖFP,http://ec.europa.eu/justice/anti‐drugs/files/report‐drug‐dependence_en.pdf

 

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Figure6.2.Coverageofharmreductionmeasures incountrieswith increasing,stableordecreasingnumbersofHIVacquiredviaIDU.

Source:http://ec.europa.eu/justice/anti‐drugs/files/report‐drug‐dependence_en.pdf Figure6.3.Changesintheavailability/coverageofinjectionmaterialsforIDUs.

 

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Figure6.4.Changes in the coverage of OST, psychosocial care (PSC) and rehabilitation supporting OST and drug‐free treatment (DFT) by EU membership status. 

Figure6.5.Changesinthecoverageofharmreductionmeasuresinprisons.

6.2.PoliciesrelatingtohealthcorrelatesandconsequencesTheriskbehavioursofaddictsincludeeverykindofbehaviourrelatedtodrugaddiction,

which can also lead to additional diseases and complications. These behaviours includesharing needles, syringes and other equipment and risky sexual behaviour (sexwithoutprotection).HBV,HCVandHIVarejustsomeofinfectiousdiseasesthatcanbetransmittedin theseways,meaning that the addict population is atmuch greater riskof contractingthesediseasesthanisthegeneralpopulation.Itshouldalsobenotedthatthissectionrefersnot only to the prevalence or incidence of diseases, but also to the risk factors for theirtransmission. Therefore, it is of utmost importance to insist on the implementation of

 

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measures that could reduce thepractice of sharing needles and other equipment and tocontinuallyraiseawarenessoftheirimportance.

TheFormerYugoslavRepublicofMacedonia is a lowHIVprevalence countryandhasreportedthelowestnumberofHIVpositivecasessofaramongthecountriesinthesouth‐easternEuropeanregion.ThefirstHIVinfectionwasregisteredinthecountryin1987andthefirstAIDScasein1989.ThefirstdeathfromAIDSwasregisteredin1990.

HIV/AIDS testing can be carried out in all public health institutes and clinics forinfectious disease, and byNGOs. Free tests for HIV/AIDS are available in 14 centres forpublichealth.Testingisvoluntaryandanonymous.PregnantwomenandnursingmothersarenotobligedtobetestedforHIV/AIDS.

6.2.1.NationalStrategyforHIV/AIDS2012–16(63) This Strategy elaborates the current situation and evaluates the previous strategy,

identifying weak points and accordingly setting strategic priorities, measures andactivities.ItwasadoptedanddevelopedbytheMinistryofHealth.WithregardtotheinterventionsaimedatIDUs,thestrategicaimistomaintainthelow

prevalenceofHIVamongdrugusers.Itsrecommendedstrategicinterventionsare:1. Distribution of sterile accessories for injection, condoms, lubricants and

informationalmaterials in day care centres forMMT and in the field; preventionactivitiesagainstHIV/AIDS,andamongdruguserswhoinjectnarcotics.

2. Providinghealth,psychosocial,legalandotherservicestodrugusers.3. Improvingaccesstoprogrammesfortreatmentandrehabilitationwithsubstitution

therapy.4. Creatinggender‐specificprogrammesforthetreatmentandrehabilitationofdrug‐

dependentpeoplewhoareundergoingsubstitutiontherapy.5. Creatingspecificprogrammesforthetreatmentandrehabilitationofchildrenwho

injectdrugs.6. Increasing access to voluntary and confidential testing and consultations on

HIV/AIDSforpeopleondrugs.7. Establishingnewprogrammestoreducedruguseharmsamongfemales.8. Establishingnewprogrammestoreducedrugabuseharmsamongyoungpeople,in

cooperationwiththeCentreforSocialAffairs.9. Education and training for healthworkers andother personnel on IDU treatment

andHIVprevention.10. Improvingaccesstotreatmentwithsubstitution.11. Improvingtheactivitiesoftheservicesfortherehabilitationandre‐socialisationof

IDUs.

                                                            (63)www.moh.gov.mk 

 

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12. Providing informational and educational workshops on the prevention ofHIV/AIDS/STI/druguseforconvictedprisoners.

6.2.2.StrategyontheHealthcareofthePrisonPopulation(2012–14)andActionPlanThisstrategyaddressesthehealthprotectionneedsofconvictedprisonersandminors inthecriminalcorrectionalsystemandeducationalcorrectionalsystem.It identifiesseveralareaswherechangeisneededinthematerial,administrativeandorganisationalaspectsofhealthcare.In 2012–13 the Administration for the Execution of Sanctions carried out numerous

activities related tohealthcare inprisons.Prison reform in the fieldofhealthprotection,which is the responsibilityof theAdministration for theExecutionofSanctions, includesspecific categories of prisoners, including drug users. The Government adopted theStrategyontheHealthcareofthePrisonPopulation(2012–14)andActionPlan.Theuseofnarcoticshasbeenhighlightedasoneofthemainproblemfacingtheprison

system. There has been a rapid increase in dependency on psychoactive substances,predominantlyheroinandtablets,reflectingthesituationinsocietyasawhole.Problemsrelating to drug use are increasing, which underlines the importance of increasedawareness.Drug addiction treatment involves improving the quality of life of the individual, and

reducing the risk to the prison community. Treatment is directed towards improvingpsychophysical health, stimulation and maintenance of good mental health in theindividual, reducing damage from drug use and preventing the spread of disease andinfections. The specific needs of IDUs particularly highlight the requirement for astandardisedandeffectiveeducational,healthandpsychosocialprogrammewithinprisons,andtheimportanceofadvocatingforaneffectiveprisonhealthservicethatcanrespondtothechallengesitfaces.Thesituationanalysesofthestrategyhighlightedalackofstandardisedproceduresand

instructions for prison healthcare provision, and a need to improve material, technical,hygienic,organisationalandadministrativeaspects.TheStrategyontheHealthcareofthePrisonPopulationaimstodevelopaprofessional

andmultidisciplinaryapproachtoimprovinghealthprotectionforallthoseincorrectionaland educational institutions in accordance with international standards, a respect ofhumanrightsandtheprovisionofhealthcare.

6.2.3.Interventionstopreventinfectiousdiseases

TheRepublicInstituteforPublicHealthcollectsnationwidedataoninfectiousdiseases,includingHIVandhepatitis.Additionaldataondrug‐relatedinfectiousdiseasescomefromthe bio‐behavioural studies conducted in 2005, 2006, 2007 and 2010within the projectsupportedbytheGlobalFund.

Twenty cases of HIV/AIDS were registered in 2012, which is the largest number ofnewly discovered cases per year since 1987. In total, 166 cases of HIV/AIDS were

 

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registered since 1987, of which 69 died. The trend for transmission of HIV infection iscontinuing.Heterosexual transmission is themostcommonroute(99cases), followedbyhomosexual transmission (42 case). There have only been two cases where IDU wasspecifiedastherouteofinfectiontransmissioninthepasteightyears.

According to the Institute for Public Health(64), there were 154 HBV patients in2011 (98 male and 56 female), and 184 in 2012 (102 male and 82 female). The totalnumberofHCVpatientswas76 in2011 (60maleand16 female)and165 in2012(117maleand48female).Table6.1.AnalysesperformedbytheDepartmentofVirologyandMolecularDiagnostics,2012.Parameter Negative Positive TotalHBs* 987 36 1 023HCV 690 102 792HIV 1 057 0 1 057*Resultsformarkersarenotincludedinthisnumber(antiHBs,antiHBctotal,antiHBcIgM,HbeAg,antiHbe)forwhich402analysiswereperformed.Source:InstituteforPublicHealth.

During 2012 a total of 48 patients began treatment in the Clinic for InfectiousDiseases,Skopje Clinical Centre. Ninety‐seven people are currently living with HIV/AIDS. Theyoungestpatientwas4yearsofage,whiletheoldestwas64.Mostpatients(68cases)wereaged20–39.Therewereeightcasesaged0–19.A6‐year‐oldchildwasamongthosereported,whois theyoungestpatientsufferingfromAIDS. The virus was transmitted from the mother while she was pregnant. HIV wasdiagnosed when the child attended a paediatric clinic for treating inflammation of thebrain.Specificsymptomsalerteddoctors,whocarriedoutadetailedanalysisandHIVtest.The child was immediately transferred for treatment to the Infectious Diseases Clinic.6.2.4.Drug‐relateddeathsandemergenciesDeathsrelatedtopsychoactivedruguse(drug‐relateddeaths)refertothosethatarea

consequenceofacuteintoxicationwithoneormoredrugs,anddeathscausedbyillnessesdevelopedduetodruguse(e.g.cardiovascularproblemsincocaineusers),riskyaddictionbehaviour(hepatitis)ordrug‐relatedaccidents.The total number of drug‐related deaths depends onmany factors, such as frequency

androuteofadministeringdrugs(intravenous,simultaneoususeofmoredrugs),ageoftheaddictionpopulation,concurrentdiseasesanddisorders,andtheavailabilityoftreatmentandemergencyservices.According to the EMCDDA definition, drug‐related deaths (DRD) refer to deaths that

occurshortlyaftertheuseofoneormoredrugs,althoughveryofteninsuchcasesalcoholandothermedicationarealsofoundtobepresent.

                                                            (64)G.Kuzmanovska(2013),InternalreportforHVBandHVC,InstituteforPublicHealth,Skopje,January.

 

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The Former Yugoslav Republic of Macedonia adopted this definition, and since 2007institutesfor forensicmedicinehavereportedDRDstotheNFPasthereferentcentreforcooperationwiththeEMCDDA.DRD cases are confirmed following an autopsy. Article 275 of the Law on Health

Protection (Official Gazette of the Former Yugoslav Republic of Macedonia, No. 43/12,10/13)definesamedicalautopsy:

When it is obvious or suspected that death is not from natural causes, forensicmedical autopsy and forensic medical expertise is performed on the body of thedeceasedbytwophysicians,oneofwhichshouldbeadoctorofmedicine—forensicspecialist.

Aforensicmedicalautopsyisperformedinthefollowingcases:1)Homicideorsuspectedhomicide,orsuicideorsuspectedsuicide.2)Suspectedmedicalerror.3)Technologicalandenvironmentaldisasters.4)Whenrequiredtoprotectthehealthofcitizens,or forepidemiological,sanitaryandscientificreasons.5)Unexpecteddeathwhenthecauseofdeathisunknownorunclearorcannotbeexplained, including sudden infant death and when death has occurred inconnectionwithadiagnosticortherapeuticprocedure.6)Deathindetention,injail,afterpolicedetention.7)Deathsuspectedtobeasaresultoftortureorinhumantreatment.8)Deathassociatedwithpoliceormilitaryactivity;unidentifiedbodies.9)Atarequestofaclosefamilymemberofthedeceasedperson.10)Thebodyof apersonwhodied inamental institution subject topathologicalandanatomicalautopsy.

An autopsy will be conducted in cases of unnatural death or death by unknown origin,deathduringdiagnosticortherapeuticintervention,deathwithin24hoursofadmittanceofthepersontoamentalinstitution,deathofapersonwhoparticipatedinaclinicaltrialofadrugormedicaldevice,orinascientificinvestigationinahealthfacility,orincasesofthedeathofapersonwhosebodypartscanberemovedfortransplantationinaccordancewithlaw.

6.2.4.1.RegistrationofdataonDRD Drug‐related deaths are registered by the General Mortality Register of the National

StatisticalOffice and two special registers thatprovide country‐widedocumentation: thePolice Register of the Ministry of Internal Affairs and the Register of the Institutes forForensicMedicine.However,theNFPreceivesthemostup‐to‐datedatafromfourbodies:the Institute of Forensic Medicine, Criminology and Medical Deontology at the MedicalFaculty in Skopje, the Institute of Forensic Medicine in Bitola, the Institute of ForensicMedicineinShtipandtheInstituteofForensicMedicineinTetovo.DatafromtheGeneralMortalityRegisterisstatisticallyvaluated,withatwotothreeyeardelay,anditisdifficult

 

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toobtainseparatedataonDRDwithouttheinclusionofdataonothertypesofpoisoning(fromtoxicchemicals).

In 2012 the Forensic Toxicology Laboratory at the Institute of Forensic Medicine,Criminology and Medical Deontology was equipped with modern and sophisticatedequipment, provided by Government. This equipment allows the Forensic ToxicologyLaboratorytoperformqualitativeandquantitativeanalysisofbiologicalmaterialfromcadaverspecimenand livepatients, includingquantitativedeterminationofalcohol inbloodandurinebyusingGC/FID;qualitativeandquantitativedeterminationoforganictoxic substances in body fluids, organs andhair, food andbeverages byusingGC/MSand LC/MS. The challenge for the forthcoming period is to increase the Laboratory’sskillsinthequalitativeandquantitativeanalysisofbiologicalmaterialusingtheabove‐mentionedchromatographytechniques.ThemainobjectiveoftheForensicToxicologyLaboratoryistoexpandtobecomearegionalforensictoxicologylaboratory.

6.2.4.2.Codingsystem

InaccordancewithEUstandards,DRDcasesarecountedwhenthedeathwasduetopoisoningbyaccident,suicide,homicideorundeterminedintent.Casesareincludedwhenthedeathwasduetoopiates,amphetamines, cocaine(orcrack), cannabis,hallucinogens,solventsorsyntheticdesignerdrugslikeamphetaminederivatives.

Theprecisegroupsofdeathsare:

Categoryofdrug‐relateddeath SelectedgroupsPoisoningbyaccident,suicide,homicideorundeterminedintent

Opiatesonly(excludingmethadoneonly)MethadoneonlyPoly‐substancesincludingopiatesPoly‐substancesexcludingopiatesUnspecified/unknown

The Special Register at the Institute of Forensic Medicine, Criminology and Medical

DeontologyusesstatisticsbasedontheWHOInternationalClassificationofDiseases,ICD‐10.

 

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6.2.4.3.Characteristicsofthecases Figure6.6.NumberofDRDcasesin2011,2012andthefirstsixmonthsof2013.

 

Source:FormerYugoslavRepublicofMacedoniaNFP. Figure6.7.TrendinthecauseofDRDin2011,2012andthefirstsixmonthsof2013.

 

Source:FormerYugoslavRepublicofMacedoniaNFP,evaluatedreportsreceivedfromtheInstituteofForensicMedicine,CriminologyandMedicalDeontologyattheMedicalFacultyinSkopje. 

Table6.2.CharacteristicsofDRDin2011,2012andthefirstsixmonthsof2013.Drug‐relateddeaths 2011 2012 2013

(first6months)

Methadone 4 4 2Opiates 4 2 1Cocaine 1 0 1Amphetamine 0 2 0Cannabis 0 0 1Methadone+BZD 3 10 10

 

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Methadone+BZD+Cannabis+cocaine

0 0 1

Opiates+methadone 1 0 0Opiates+amphetamine

0 0 1

Methadone+cannabis

0 0 1

Methadone+BZD+cannabis

1 0 0

Opiates+methadone+cannabis

0 0 1

Total 14 18 19Source:FormerYugoslavRepublicofMacedoniaNFP,evaluatedreportsreceivedfromtheInstituteofForensicMedicine,CriminologyandMedicalDeontologyattheMedicalFacultyinSkopje. 

 Table6.3.DRD:agebreakdownin2011,2012andthefirstsixmonthsof2013. N Average Min Max

2011 14 26 18 402012 18 31 21 412013(first6months)

19 32 11 50

Source:FormerYugoslavRepublicofMacedoniaNFP,evaluatedreportsreceivedfromtheInstituteofForensicMedicine,CriminologyandMedicalDeontologyattheMedicalFacultyinSkopje. 

Figure6.8.IncreaseinDRDduetomethadone,oftencombinedwithBZD.

 

6.2.5.Interventionstopreventandreducedrug‐relatedharminrecreationalsettings

6.2.5.1.AcuteintoxicationwithpsychoactivesubstancesAccording to information on acute intoxication from the Toxicological Information

CentrePHI,UniversityClinicofToxicology,in2011therewere11casesofacutecannabis

 

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intoxication,threeofecstasy,27ofmethadone,15ofheroin,6ofcocaineand12ofnarcoticanalgesics. Table6.4.Acuteintoxications,bytypeofdrugandageofvictim(65). Age Type ofpsychoactivesubstance

1–4 5–14 15–19 20–74 Over75 Ofthetotal,detainedinhospital

Totalintoxication

Benzodiazepines 16 14 37 228 3 184 298Antidepressants / 1 2 27 / 28 30Neuroleptics 1 3 2 21 / 22 27Opioidanalgesics 0 3 1 14 / 8 18Hypnotic / / 1 5 / 5 6Methadone / / 1 30 / 11 31Heroin / 1 / 15 / 0 16Cannabissativa / / 4 6 / 0 10Cocaine / / 1 7 / 2 8Ecstasy / / 1 2 / / 3Buprenorphine 4 / / / / 4 4Total 21 22 50 490 3 264 451Source:ToxicologicalInformationCentre. DatafromtheToxicologicalInformationCentreindicatesthat66%ofthe451casesof

acute intoxication with psychoactive substances were due to drugs from the group ofbenzodiazepines. This situation highlights the need to conduct research in this field todeterminethecauses. 

6.2.6.QualityassuranceinharmreductionInFebruary2013theAdministrationfortheExecutionofSanctions(which,accordingto

Article9oftheLawontheControlofNarcoticDrugsandPsychotropicSubstances, istheresponsiblebody forallprisonssettings in thecountry,especiallywithrespect topeoplewithdrugaddictionsinprisons)adoptedandbeganimplementingtwelvemanualsonthehealthcareofdrugusersinprison.The manuals give instructions on different areas of healthcare in penitentiary and

correctionalinstitutions.Theycoveredfollowingareas:- the duties and ethics of the medical staff of the healthcare sector in the

institution;- controlandhygiene,controlofservingfoodanddrinkingwaterinthefacilities;- cooperation of the healthcare sector in the institution with the resettlement

sector and security sector, cooperation with other criminal correctionalinstitutionsandmedicalfacilitiesoutsidetheinstitution;

- minimum technical standards (concerning facilities, equipment, staff) for thehealthunitsintheinstitutions;

                                                            (65)P.Zanina(2012),Annualreportofpoisoninginthecountryfor2012,ToxicologicalInformationCentre,Skopje,0302‐26012.

 

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- medicalexaminationatthereleaseofadetainee;- prisoners’ access to a doctor, distribution of medicines, medical examination

outsidetheinstitution;- medical examination and medical supervision during the execution of

disciplinary punishment of isolation of three to 15 days, with andwithout therighttowork;

- procedure for a medical examination for use of force against detainees andconvictedperson;

- procedureforthemedicalmanagementofprisonersonhungerstrike;- procedure for the separation of remand and convicted prisoners, and juvenile

detainees;- instructions for medical examination at the release of convicted minors from

institutions;- procedure for recognising and recording signs of violence among convicted

prisoners in the institution to the and the procedure for registering visibleinjuriescausedbyviolenceagainstinmatesduringajailsentence;

- procedure formedical examination on admission of convicted juveniles in theinstitution;

- procedureformedicalexaminationofdetaineesonadmission.In2013theAdministrationfortheExecutionofSanctionspreparedandadoptedthreeprotocols in the field of health protection of convicted persons: the Protocol for theHealthcare of Convicted Persons with Communicable Diseases(HIV/AIDS/tuberculosis/hepatitis/STI); theProtocol for theDistributionofCondoms inPrison; and the Protocol for Replacement Therapy among Convicted Persons who areDrugUsers.InDecember2013twoworkshopswereheld(withthesupportofTAIEX,theTechnicalAssistance and Information Exchange instrument managed by the Directorate‐GeneralEnlargement of the European Commission) to train prison staff on the prevention ofviolence in prison and the programme for anger management, and on healthcare inprisons.IdrizovoPrisonintroducedpsychosocialsupport forconvictedprisonerswhoaredrugusers.Themanuals,protocolsandworkshopsweredefinedasgoals intheActionPlanoftheStrategyontheHealthcareofthePrisonPopulation(2012–14).6.3.NeedleandsyringeexchangeprogrammesDatahaveindicatedthatthereisalowprevalenceofHIV/AIDS,especiallyamongIDUs,butthe countryhasexperienceda large increase inHCVcases.NeedleandsyringeexchangeprogrammeshavemadeasubstantialcontributiontothelowprevalenceofHIV/AIDS.Theprogrammes have been financed by the Global Fund for a number of years, and areimplementedbyNGOs.

 

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HarmreductionactivitiesaredefinedintheNationalStrategyforHIV/AIDS.TheseactivitiesareprohibitedundertheCriminalCode(elaboratedinthesectionforlegislationin this report, 1.1.). Health services wishing to offer these services (within the NGOprogrammesforexchangeofneedleandsyringes)mustmeetstrictlegalparameters(Lawfor Healthcare), with clearly specified facilities, equipment and staff in medical clinics.Harmreductionprogrammesarenotsubjecttoanyhealthinspectionthatwouldsuperviseandcontroltheirhealthinterventions.

In2011therewere16harmreductionprogrammes,allofwhichweremanagedbyNGOswithfinancialsupportfromtheGlobalFund.TheNGOHOPSranfourprogrammesinSkopje, including a programme for sex workers who inject drugs. Harm reductionprogrammeshadcontactwith2952uniqueclientsin2011.Ofthese,582werenewclients,incontactwiththeprogrammesforthefirsttime.Atotalof17.7%ofallnewclientswerewomen.

Table6.5.Numberofuniqueandnewclientsinharmreductionservices,2011.City Uniqueclients Newclients Totalcontacts

Male FemaleSkopje 707 137 30 12426Strumica 310 75 7 5810Kumanovo 121 17 6 2759Gostivar 384 31 16 1100Kavadarci 40 9 3 1003Stip 104 7 1 2360Tetovo 89 25 22 760Ohrid 202 28 2 1033Bitola 474 75 6 5460Kichevo 120 22 0 830Prilep 106 19 3 816Veles 144 18 2 1041Gevgelija 151 16 5 3578Total 2952 479 103 38976Source:HOPS

Table6.6.Numberofsyringes,needlesandcondomsdistributed,bycity,2011.City Needles Syringes Condoms Programmes

Skopje 290625 121755 14926 4Strumica 55332 24437 13300 1Kumanovo 16945 12101 6856 1Gostivar 15248 10957 8090 1Kavadarci 7489 3 492 1 135 1Stip 8632 3 588 1 153 1Tetovo 11660 9773 5998 1Ohrid 29979 14358 9939 1Bitola 159749 99156 18980 1Kichevo 3724 1862 822 1Prilep 14657 7 552 7 593 1Veles 7295 4 365 1 623 1

 

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Gevgelija 15575 5 089 4 706 1Total 636910 318485 95121 14In2011harmreductionprogrammesdelivered41986medicalservices,mostofwhich

werebasicmedical intervention— intervention/treatmentof long‐termornot adequateinjection, counselling and education on drugs and the consequences of drug use,informationontreatmentandreferralstotreatment.Social workers delivered 25788 services, most of which were to obtain identity

documentsandotherpersonaldocuments(e.g.birthcertificate),assistancewithobtaininghealth insurance and social support, referrals to institutions and legal advisers, andindividualpsychosocialsupport.Table6.7.Numberofmedicalandsocialserviceswithinharmreductionprogrammes.City Medicalservices SocialservicesSkopje 14625 5913Strumica 1753 3 001Kumanovo 2676 651Gostivar 1412 887Kavadarci 6890 1 365Stip 1562 3329Tetovo 983 3 464Ohrid 1622 1484Bitola 1535 1271Kichevo 5141 2 685Prilep 1393 1141Veles 2394 597Gevgelija ‐‐ ‐‐Total 41986 25788Source:HOPS6.4.VoluntarycounsellingandHIVtesting HIV/AIDStestingisavailableinallpublichealthinstitutes,clinicsforinfectiousdisease,

and via outreach programmes. In order to include asmany people as possible from thevulnerablepopulation(peoplewhoinjectdrugs,sexworkers,menwhohavesexwithmen,young people), Centres for Voluntary Counselling and Testing (VCT) for HIV/AIDSweredeveloped.Thereare13VCTcentres, locatedintheInfectiousClinic,PolyclinicBitPazar,theNationalInstituteforHealthand10CentresforHealthProtection.HIV/AIDS counsellingprovides awide rangeofHIV/AIDS services, includingpre‐ and

post‐testingconfidentialandvoluntarycounselling,provisionofHIV/AIDS treatmentandcounselling, palliative and social care for people living with HIV/AIDS, free condoms,educational materials and other preventive and counselling services within the jointprogramme,andcooperationwiththeClinicforInfectiousDiseasesandFebrileConditions.TwelveNGOscooperatewiththePublicHealthInstitutetoimplementVCTonoutreach,

visitinglocationssuchasstreets,parks,abandonedproperties,etc.thatarefrequentedbydrugusers.

 

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The NGO Hera operates a free telephone helpline for people to ask questionsrelatingtoHIV/AIDSandsexuallytransmittedinfections. In2011atotalof638VCTswereconductedwithdrugusers;nonewerefoundtobeHIVpositive. Table6.8.NumberofHIVtests,2011. Male Female TotalHIVtests 552 86 638Table6.9.Employmentstatusofdrugusers,bycity.City No of

drug users

Employed Unemployed Temporary employed

Honorary Other

N % N % N % N % N % Skopje 167 16 9.58 133 79.64 2 1.20 8 4.79 8 4.79Strumica 82 9 10.9 59 71.9 7 8.5 7 8.5 0 0Kumanovo 23 1 4.35 21 91.30 1 4.35 0 0 0 0Gostivar 47 2 4.25 19 40.4 20 42.5 3 6.38 3 6.38Kavadarci 12 2 6 6 50 1 12 3 32 0 0Stip 8 0 0 7 87.5 0 0 1 12.5 0 0Tetovo 47 6 12.76 32 68.09 9 19.15 0 0 0 0Ohrid 30 3 10.00 25 83.33 2 6.66 0 0 0 0Bitola 81 2 3 52 64 26 32 n/a n/a 1 1Kichevo 22 0 0 22 100 0 0 0 0 0 0Prilep 22 4 18.18 15 68.18 0 0 3 13.6 0 0Veles 20 1 5 19 95 0 0 0 0 0 0Gevgelija 21 2 9.5 17 80.9 2 9.5 0 0 0 0Total 582 48 8.3 427 73.4 70 12 25 4.3 12 2Source:HOPS

Thecharacteristicsofclientsofneedleandsyringeexchangeprogrammeswererecordedas evidence of personal client data,mostly socio‐demographic factors, including data onemployment. Inaddition to itsuse inanalysis, thedatacanalsobeuse tomakepossiblerecommendationsforemployment,iftheclient'squalificationsandmedicalconditionallowit.

 

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Figure6.9.EmploymentstatusofPDUclientsofneedleexchangeprogrammes.

Only30%oftheclientsofharmreductionprogrammeshadsomeformofemployment.Table6.10.Newharmreductiontreatmentclientswithorwithouthealthinsurance,2011.City Noofnew

clientsin2011

Healthinsurance Withoutinsurance

Other

N % N % N %Skopje 167 125 74.85 40 23.95 2 1.20Strumica 82 79 96.3 3 3.65 0 0Kumanovo 23 20 86.96 3 13.04 0 0Gostivar 47 38 80.8 9 19.1 0 0Kavadarci 12 12 100 0 0 0Stip 8 7 87.5 1 12.5 0 0Tetovo 47 40 85.11 7 14.89 0 0Ohrid 30 30 100 0 0 0 0Bitola 81 79 98 2 2 0 0Kichevo 22 22 100 0 0 0 0Prilep 22 21 95.45 1 4.54 ‐ ‐Veles 20 20 100 0 0 0 0Gevgelija 21 19 90.4 2 19.04 0 0Total 582 512 88 68 11.7 2 0.3Source:HOPSTable6.10showsthat88%ofPDUshadhealthinsurance,eventhoughonly30%were

employed.This indicates that theywere coveredby someof the specialprogrammes forvulnerablegroupsfromthegovernment’sbudget(ProgrammeforPersonswithAddiction,SocialCareProgramme,etc.). Healthinsuranceallowspeopletoobtainhealthcareinterventionswithoutpaymentor bymaking a small payment, andmedicines included in the ‘Referent List’ which arereimbursedbytheStateHealthInsuranceFund(66).

                                                            (66)http://www.fzo.org.mk/

 

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6.5.Informationonproblemdrugusersfromnon‐treatmentsourcesPDUsintreatmentarediscussedindetailinSection5ofthisreport.Following the intervention of the Ombudsman, after a request from 20 NGOs, the

MinistryofInternalAffairsisnolongerallowedformallytokeeprecordsofpeoplewhousedrugsandweresubjecttoanadministrativeorcriminalsanction.Moreover,thisregister,whichwasalwaysuptodateandwasextremelyusefulforcomparingdatafromdifferentdatabases,cannotbeusedanymore,norcanitsdatabepublished,eventhoughithassofarbeenprotecteddatathatdidnotdisclosetheidentityofdrugusers. Data from harm reduction programmes show that 454 (78%) of 582 drug userswerepolydrugusers;10.8%onlyusedheroin. Table6.11.Numberofnewclients,bytypeofdrugused.City Polydrug Heroin Methadon

eMarijuana

Sedative/

diazepam

Analeptic

EcstasyAmphetamine

LSD

Noanswer

Total

Skopje 92 32 29 6 2 1 1 1 0 3 167Strumica 68 6 8 82Kumanovo

16 4 3 23

Gostivar 42 5 47Kavadarci 12 12Tetovo 47 47Stip 8 8Ohrid 30 30Bitola 76 4 1 81Kichevo 22 22Prilep 4 12 1 3 2 22Veles 16 0 2 2 0 0 0 0 0 0 20Gevgelija 21 21Total 454 63 44 11 2 1 1 1 0 5 582Source:HOPS In 2012 therewere 16 active programmes to reduce damage caused by drug useacrossthecountry,allrunbyNGOswithfinancialsupportfromtheGlobalFund.TheNGOHOPSledfourprogrammesinSkopje,alongwithaspecialprogrammeforsexworkerswhoinjectdrugs.

In terms of how drugs are administered, 454 (77.84%) of 582 new clients in harmreductionprogrammesin2011injecteddrugs,adecreaseof3%comparedwith2010.Itshouldbeemphasisedthatharmreductionprogrammesareintendedforpeoplewhoinjectdrugs,hencethenumberofinjectingdrugusersislarge.

 

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Table6.12 Do you inject? Yes No NoanswerSkopje 130 34 3Strumica 73 6 3Kumanovo 23 0 0Gostivar 33 14 0Kavadarci 12 0 0Tetovo 33 14 0Stip 7 1 0Ohrid 29 1 0Bitola 81 0 0Kichevo 12 2 8Prilep 20 2 0Veles 13 7 0Gevgelija 20 1 0Total 486 82 146.6.Harmreductionprogrammes (sharingneedles,OST,counsellingcentresandsupport)inSkopjein2012 

A total of 684 unique clients attended the NGO HOPS’ harm reduction programmes inSkopjein2012.Ofthese,146werenewclients,makingcontactforthefirsttime.Intermsofgender,12.3%ofnewclientswerefemale.Table6.13.NumberofuniqueandnewclientsattendingNGOsinSkopje,2012.City Unique

clientsNewclients Total

number ofcontacts

Male Female

Skopje 684 128 18 11 101Source:HOPS.

Table6.14Numberofneedles,syringesandcondomsdistributedinSkopje,2012.City   Needles   Syringes 

 Condoms  Programmes

Skopje 291991 111542 17535 4

Source:HOPS. 

In 2012 harm reduction programmes delivered 13001medical services, most ofwhich were basic medical intervention — intervention/treatment of long‐term or notadequateinjection,counsellingandeducationondrugsandtheconsequencesofdruguse,informationontreatmentandreferralstotreatment. Socialworkersdelivered5351services,mostofwhichweretoobtainIDandotherpersonaldocuments(e.g.birthcertificate),assistancewithobtaininghealthinsuranceand

 

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socialsupport,referralstoinstitutionsandlegaladvisers,individualpsychosocialsupport,informativeadvice,referralstoemploymenttraining,orinformalconversations. HOPSco‐operateswith thePublicHealth Institute to implementVCTonoutreach,andtheyvisitlocations(streets,parks,abandonedproperties,etc.)thatarefrequentedbydrugusers. In 2012 HOPS conducted a total of 69 VCTs with drug users (57 male and 12female);nonewerefoundtobeHIVpositive.Table6.15.EmploymentstatusofdrugusersinSkopje,2012.City Number

ofdrugusers

Employed Unemployed Temporaryemployed

Honorary Other

N % N % N % N % N %

Skopje 146 16 10.9 118 80.8 2 1.4 6 4.1 4 2.7

Source:HOPS

Table6.16.SocialandhealthinsurancestatusofnewclientsinSkopje,2012.City Numberof

newclientsin2012

Withhealthinsurance

Withouthealthinsurance

Other

N % N % N %

Skopje 146 100 68.5 43 29.5 3 2

Source:HOPS

In2012,ofthe146newclientsinharmreductionprogrammes,78(53.4%)werepolydrugusers;16(10.9%)onlyusedheroin;and55(29.1%)weresingle‐drugusers. Table6.17.TypeofdrugusedbynewclientsinSkopje,2012.City Polydrug Heroin Methadone Marijuana Sedative/

diazepamEcstasy Amphetamine LSD No

answerTotal

Skopje 78 56 71 64 31 6 4 1 0 146

Source:HOPS

Intermsofhowdrugswereadministered,92(63%)of146newclientsinjecteddrugsin2012. Table6.18NumberofnewclientsinSkopjewhohadinjectedanarcoticdrug,2012. Yes No Noanswer

Skopje 92 48 6

 

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7.SOCIALCORRELATESANDCONSEQUENCES

7.1.TreatmentofdrugusersinprisonThe implementation of guidance for equal care recommended by the World Health

Organizationmeansthatprisonershavetherighttoreceivehealthcareequivalenttothatavailableinthecommunity. Table7.1.Overviewofdrugusersreceivingtreatmentinprisonsettings,2011.PRISON Total

numberofprisonersin

2011

Numberofimprisoneddrugusers

Prisonersonmethadonetherapy

Prisonersonbuprenorphinetherapy

%ofdrugusers

Idrizovo,Skopje 1316 388 154 5 29.4

Skopje 173 130 116 4 75

Kumanovo 0 0 0 0

Shtip 232 22 18 0 9.4

Strumica 105 21 10 1 20

Gevgelija 68 17 14 2 25

Bitola 85 71 69 2 83

Prilep 65 13 1 0 20

Ohrid 21 17 6 1 80.9

Struga 43 12 9 2 27.9

Tetovo 86 28 16 0 32.5TetovoEducationalCorrectionalInstitution

13 1 0

Total 746 414 17

Source:NationalReport for2011of theAdministration forexecutionof sanctionson theconditionandoperationof thecriminalCorrectionalandcorrectionalinstitutionsintheFormerYugoslavRepublicMacedonia,2012.

In 2012 and 2013 all prisoners had access toOST. Three centreswere active in the

threemain prison facilities in two cities, Skopje and Bitola. Prisoners at other locationswereintegratedintocommunityOSTprogrammes,andreceivedsubstitutiontherapyandpsychosocial support from the nearest community treatment centre. The programmes

 

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ensuredasmoothtransitionbetweenprisonandcommunityprovisionofMMTfollowingimprisonment.ThetotalnumberofprisonersinOSTin2012was420.FurtherdetailsareprovidedinSection5.

 

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8.RESPONSESTOSOCIALCORRELATESANDCONSEQUENCES

Themaincausesofpovertyandsocialexclusionarelong‐termdependenceonaloworinadequate income, long‐term unemployment, low‐paid and/or low‐quality jobs, a lowlevelofeducationandtraining,childrenbeingraisedinvulnerablefamilies,theimpactofphysicalandmentaldisabilities,rural/urbandisparities,racismanddiscrimination,and,toa lesserextent,homelessnessandmigration.The linkbetweenunemploymentandsocialexclusionisparticularlysignificant.Reintegrationinitswidestsensemeanseveryformofsocial inclusionand involvement throughvariousactivities in the fieldsof sport, culture,work and other social activities. Therefore, the social reintegration of addicts shouldlogically follow psychosocial rehabilitation.However, addicts receiving treatment cannotsuccessfullyintegrateinsocietyforanumberofreasons,includingpublicopinionondrugaddiction, which marginalises, stigmatises and excludes the entire population of drugaddictsfromtheirworkandschoolsettings.8.1.SocialreintegrationofdrugaddictsThreedaycentresforsocialreintegrationareoperatinginthecountry.Theyofferpatientstheopportunitytostabiliseandnormaliseprogresstheyhavemadewithprevioushealthinterventions.Peoplewithproblemsduetodrugaddictionarepartofaverysensitiveandvulnerable group, and the activities and interventions that are provided requireconsiderableplanning,andmayneedtobeprovidedoveralongperiodoftime.

The day centres provide programmes for active participation and for obtaining newskills, work re‐training programmes, psychosocial interventions and support in order tospeed up the process of re‐socialisation, social reintegration and effective inclusion ineverydaylife.Themodelisbasedonthesupportofthecommunityasawhole,withtheinvolvementof

different professionals. TheMinistry of Labour and Social Policy has already establisheddaycentresinOhrid,KumanovoandStrumica.InaccordancewiththepoliciesandactivitiesoftheMinistryofLabourandSocialPolicy,

intheframeofthesocialprotectionofdrugabusers,adaycentreisalsoplannedforSkopje,wheretheneedsaregreatest.The reasons foropening the centres canbeobserved in thegoals, tasksandactivities

outlinedintheSkopjecentre’sworkingprogramme:

GOAL:To strengthen and improve the rehabilitation and reintegration of individuals in themunicipalityofSkopjewithsocialproblemsthataretheconsequencesofdrugabuse.

TASKS:x Earlyandtimelyinterventionswithintensiveandindividualattentiontothedrugusers.x Toprovideaplacewhereproblemsanddifficultiescanbeovercome.

 

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x Tostrengthenfamiliessothattheycansuccessful faceandsolvetheproblemscausedbydrugabuse.

ACTIVITIES:x Organised counsellingwith parents and othermembers of the family; individual and

groupwork.x Atelephoneinformationlinetoprovideinformationtothosewishingtotakepartinthe

activities.x Aclassroomwithcomputers.x Sportsactivities,artclub,aworkshopforthepreparationofhandicraftsfromdifferent

materials.Socialexclusionamongdrugusers,anddruguseamongsociallyexcludedgroupsSocial policy and assistance topeoplewhoare social excluded, especiallypeoplewith

disabilitiescausedbydrugabuse,areintheframeworkoftheactivitiesoftheMinistryofLabourandSocialPolicy.The Law for Social Protection enables the establishment of day centres for people

addictedtodrugs,inordertoprovideservicessuchasinformation,counselling,education,work training, cultural and recreation activities, etc. for the addicted persons and theirfamilies. These day centres are a new form of non‐residential specialised addictiontreatmentservice.Thecentresareorganisationalunitsofthesocialworkdepartments inthemunicipalityinwhichtheyarelocated.8.2.ResponsestosocialcorrelatesandconsequencesinthenewNationalDrugsStrategyItisexpectedthatthefollowingtwoobjectiveswillbeimplementedasaresultofresponsestosocialcorrelatesandconsequences,concerningdrugusersinprisons:1.Within the criminal justice system,where appropriate, the capacity for assisting drugaddicts who are serving a prison sentence, in terms of education and preparation forresettlementandsocialreintegrationuponcompletionofsentence,willbeincreased.2.Measureswillbefurtherdevelopedandmadeavailabletoreducethedemandfordrugsinprison(treatmentandrehabilitation),basedonaproperassessmentofthehealthstatusandneedsofprisoners, inordertoachievecarethatisequivalenttothatprovidedinthecommunityandinaccordancewiththerighttohealthcareandhumandignityregisteredintheEuropeanConventiononHumanRightsandtheCharterofFundamentalRightsoftheEuropeanUnion.Continuityofcareshouldbeensuredatallstagesofthecriminal justicesystem,includingwhenthepersonwhohasservedaprisonsentenceisreleased.

 

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9.DRUGMARKETS9.1.ThegeneralsituationregardingdrugsupplyactivitiesIn 2012 the quantity of drugs seized on the country’s territory increased slightly

comparedto2011.CooperationbetweenthepoliceandCustomsAdministrationondrugsseizuresimprovedandseveralsuccessfulinternationalpoliceoperationstookplacetocutdrug trafficking channels.The country ison themainBalkansRoute fordrug trafficking,andtheCustomsAdministrationandtheMinistryofInternalAffairsaremakingcontinuedandsustainedeffortstodetectandseizenarcoticsattheborders.DataexchangewithpartnersincludingEuropolfacilitatesthefightagainsttheorganised

crime groups involved in drug trafficking in the region. Europol put into operation anagreementtoexchangeinformationfromalltypesofdata,includingpersonal,onalllevels.Theaimofthisagreementistostrengthentheoperativeandstrategiccooperationandtoreinforcethefightagainstseriousformsofinternationalcrime,specificallybyexchangingdata,informationandintelligence.TheFormerYugoslavRepublicofMacedoniaandCroatiaaretheonlycountriesintheregionwithsuchanagreementwithEuropol.Thistreatygivesenormousrecognition,confirmingthecountry'sabilitytomeetEUstandard.Europolseesthe Ministry of Internal Affairs as a reliable partner even for the most complex policeoperations. Regardingcustomscooperation,theCustomsAdministrationtookpartinanumberof international operations and projects to detect the illicit trade in counterfeit goods,drugs, explosives,high‐risk chemicalsandpharmaceuticals.Cooperationandexchangeofintelligence with the customs authorities of neighbouring countries intensified, as didcooperation with the relevant UN agencies. Cooperation with the regional intelligenceliaisonofficesoftheWorldCustomsOrganizationcontinued. JointinvestigationteamshaveworkedtogetheronthebasisofasignedagreementforcooperationwiththepublicprosecutorsofGermany,AustriaandtheNetherlandssince2012.Two successful joint actions in collaborationwith theAustrian andGermanpolicewerecompleted.The police have established positive links with national police directorates in

neighbouringcountries (Albania,Kosovo,Serbia,BulgariaandGreece);memorandumsofunderstandingwere signedwith various countries on fightingorganised crime anddrugtrafficking. On a case‐by‐case basis, the police have been successfully cooperating withnationalpoliceliaisonofficersfromvariousEUmemberstates,especiallyAustria,Germanyand Italy. Cooperation also exists via the Interpol andEuropol networks. Border controlefforts are being strengthened through the development of partnership and effectiveworking relationship with organisations such as Interpol, SELEC, SEPCA, Europol,EUROJUST,DCAFandUNODC.Cooperationwiththeseabovenetworksiscrucialforaneffectiveandcoordinatedaction

with the aimof tacklingorganised crime, and also for anoperational approach, due to ahighlydevelopeddatabasethatallowstheidentificationandtargetingofrepeatoffenders.This type of data makes it possible to identify “hot spots” and linked series of crimes,

 

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supplying information that helps identify preventive measures and evidence linkingoffenderstocrimes. Intheareaofpolicecooperationandthefightagainstorganisedcrime,regionaland international law enforcement cooperation throughEuropol and Interpol continued.Some225internationalarrestwarrantswereissuedin2013.TheSIENAconnectionforthesecure exchange of sensitive and operational data with Europol became operational. AliaisonofficerhasbeenassignedtoEuropol.

AmendmentstotheLawonInternalAffairsintroducedamerit‐basedcareersystemforthepolice,basedonjobcompetencies.Astrategyonhumanresourcesmanagementandamerit‐basedrecruitmentpolicywereadopted.ThePublicSecurityBureauattheMinistryof InternalAffairswas reorganised to strengthencapacities, improvepoliceperformanceandimplementEuropeanstandards.

Newstandardoperatingproceduresandguidelineswereissuedinordertoimprovethestandardofinvestigationscarriedoutatregional,localandcentrallevel,andtoensuremoreeffectiveandefficientsharingofinformation.Newproceduresforthesubmissionofrequestsforspecialinvestigativemeasureswereissued.IntheframeworkofthenewLawonCriminalProcedure,whichstartedbeingappliedfromtheendof2013,trainingofpoliceandpublicprosecutorshas continued.Aprotocol for cooperation in criminalprocedureswas signed between theMinistry of Internal Affairs, the Public Prosecutor and CustomsAdministration.

In 2013 the Department for the Fight against Organised Crime submitted 85criminal charges against 603 people to the specialised Public Prosecutor’s Office for theFight against Organised Crime and Corruption. Staffing of the department continued toimprove. A number of successful operations were carried out against organised crimegroups involved indrugsmuggling,extortion,smugglingofmigrants, facilitatingabuseofthe visa‐free regime, falsification of passports and money laundering. Four operationssucceededincuttingoffinternationalmarijuanatraffickingroutes.

There were positive developments in the area of customs cooperation. TheCustoms Administration took part in four international operations and two projects todetect the illicit trade in counterfeit goods, drugs, explosives and high‐risk chemicals.Cooperation and exchange of intelligence with the customs authorities of neighbouringcountriesandthewiderregionintensified.9.1.1.ThedomesticproductionofdrugsSelf‐cultivatedmarijuana—mainly for consumption within the country— remains themajorillegalsourceofdrugproduction.Licitpoppystrawandpoppystrawconcentratesformedicalpurposesarecontinuously

producedinthecentralandEasternpartsofthecountryinanareaofapproximately1000hectares,which itself implies an increase of 100% compared to the formerly cultivated500 hectares. Twenty‐four companies/institutions that deal with the import, export ortransitofdrugsand/orprecursorshavebeenregisteredinthecountry.

 

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9.2.NarcoticspricesThedataonpriceswerecollectedfromtwosources.PolicedataispresentedinTable9.1,anddatafromthesurveyofdrugusersispresentedinTables9.2to9.7.Section1providesinformationaboutthemethodologyofthedatacollectionfromdrugusers.Table9.1.Narcoticsprices,2013. 

Heroin Marijuana Cocaine Ecstasy BuprenorphineAmphetamine

1g 0.25g 100g 3g Joint 1 Joint 2 Couplematches

1 g 1tbl 1g

EUR11–15

MKD300–500

MKD4000

MKD500

MKD150

MKD250

MKD100–200

EUR50 MKD300–50

1tblx2mg=MKD200–3001tblx8mg=MKD500

MKD800–1000

Source:MinistryoftheInterior,FormerYugoslavRepublicofMacedonia Table9.2.Thepriceof1gofheroin,2012. N Mean Median Minimum Maximum StdDev.Price(MKD) 160 1239.4 1200.0 300.0 3000.0 437.6Source:T.Petrushevskaetal.(2012)

Table9.3.Thepriceof1gofmarijuana,2012. N Mean Median Minimum Maximum StdDev.Price(MKD) 154 166.5 150.0 60.0 600.0 88.7Source:T.Petrushevskaetal.(2012)Dataonthepriceof1gofmarijuanaweresuppliedby154(62.6%)of246respondents.TheminimumpricewasMKD60.0,andthemaximumwasMKD600.0.TheaveragepricewasMKD166.5±88.7.Thecalculatedmeanvaluesindicatethat50%ofrespondentshadpaidoverMKD150for1gofmarijuana. Table9.4.Thepriceof1gofmethadone,2012. N Mean Median Minimum Maximum StdDev.Price(MKD) 53 299.4 120.0 50.0 1 000.0 29.7Source:T.Petrushevskaetal.(2012) Dataonthepriceof1gmethadoneweresuppliedby53(21.5%)ofthe246respondents.TheminimumpricewasMKD50.0,andthemaximumwasMKD1000.0.TheaveragepricewasMKD299.4±290.7.Thecalculatedmeanvaluesindicatethat50%ofrespondentshadpaidoverMKD120.0for1gofmethadone.Table9.5.Theprice of one tablet of amphetamine,2012.   N Mean Median Minimum Maximum StdDev.Price (MKD)  35 812.9 1000 250 2000 477.6Source:T.Petrushevskaetal.(2012)

 

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Dataonthepriceofonetabletofamphetamineweresuppliedby35(14.2%)of the246respondents.TheminimumpricewasMKD250.0,andthemaximumwasMKD2000.0.TheaveragepricewasMKD812.9 ± 477.6.The calculatedmean values indicate that 50%ofrespondentshadpaidoverMKD1000.0foronetabletofamphetamine.Table9.6.Thepriceof1gofcocaine,2012. N Mean Median Minimum Maximum Std

Dev.Price(MKD) 28 3275.0 3000.0 2 500.0 6 000.0 707.4Source:T.Petrushevskaetal.(2012)

Dataonthepriceof1gofcocaineweresuppliedby35(14.2%)ofthe246respondents.TheminimumpricewasMKD2500.0, and themaximumwasMKD6000.0.The averageprice was MKD3275.0 ± 707.4. The calculated mean values indicate that 50% ofrespondentshadpaidoverMKD3000.0for1gofcocaine.Table9.7.Thepriceofoneecstasytablet,2012. N Mean Median Minimum Maximum Std Dev.Price(MKD) 51 342.2 300.0 250.0 600.0 73.1Source:T.Petrushevskaetal.(2012) Data on the price of one Ecstasy tablet were supplied by 51 (20.7%) of the 246respondents.TheminimumpricewasMKD250.0,andthemaximumwasMKD600.0.Theaverage price was MKD342.2 ± 73.1. The calculated mean values indicate that 50% ofrespondentspaidoverMKD300.0foroneEcstasytablet.

9.3.NarcoticsseizuresTable9.8.Thetrendinnarcoticsseizures,2011,2012and2013(toDecember). 2011 2012 2013

Marijuana 286kg397.8g 109kg

923 kg 480g

Heroin

23kg720.04g 76kg 124.89g

13 kg 833 g

Cocaine

1kg469.12g1.560mlliquidcocaine

48.93g 15.35gand150mlliquidcocaine

Hashish 114kg115g 26.5gAmphetamine

10.930tbland1kg819g

3.083tbland4.3 g

54tbland1.5g

Ecstasy

3.628tbl 151tblMethamphetamine

66tbland17.92g 3.083tbland4.3 g 3 tbland7.1gLsd ‐ 2pcs and61,7gCannabissativa

1.247plants1.381pcs143.86gseeds

718plants890pcs63.49gseeds

143 plants,135pcs14.37gseeds

Opium

3.7g 79.5aquasolutionofopium(withconcentr.2782.5gopium)

 

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Ephedrine

1 g ‐Diazepam

1.005amp. 115 amp. 59amp. and113tblHallucinogenousmushrooms

0.5g 128 g

Mixturetobaccoandmarijuana

28.55g 20.21g 12.93 gMethadone

600 ml1270tbl

45ml

Precursor:HCL(Hydrochloricacid)

6.5lDifferentliquidsneededforillicitproductionofnarcotics

28.2l

MDMA 72tblBuprenorphine 12tblSource:IMCND2013 In2013thecriminalactofillegaldrugtraffickingwascommittedby668perpetrators,of

which655nationalcitizensand13wereforeigners(fiveAlbaniannationals,fourTurkishnationals,twoGreeknationals,oneCroatiannationalandonePolishnational).National anti‐drug trafficking efforts and its commitment to seizing large amounts of

drugs at the country's borders in the past years appear to have led to a shift ininternationaldrugtraffickingroutes.Withthesupportofinternationalpartners(Interpol,Europol, WCO, UNODC, INCB, EMCDDA, BKA, DEA, and all regional law enforcementauthorities), the country increased its capacity by developing integrated bordermanagementandtrackingtheillicittradethroughitsborders.9.3.1Narcoticsseizuresatbordercrossingpoints,2013 Figure9.1.Locationofcustomshouses,customsofficesandbordercrossings.

Source:CustomsAdministration.

 

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Table9.9.NarcoticsseizuresbyCustomsAdministrationatbordercrossingpoints,2013.

No. DateBordercrossingpoint

Import/export vehicle

Quantity(grams) Type

1 08.01.2013 Megitlija ExportTransportmotorvehicle 301454.00Marijuana

2 12.01.2013 Tabanovce ExportPassengermotorvehicle(PMV) 14570.00Marijuana

3 28.01.2013 Tabanovce Export Bus 126295.00Marijuana4 29.01.2013 Tabanovce Export Bus 1945,00Marijuana5 06.02.2013 Tabanovce Export PMV 1985.00Marijuana6 10.02.2013 DeveBair Export Bus(passenger) 1030.00Marijuana7 15.02.2013 Tabanovce Export PMV 14275.00Marijuana

8 01.03.2013 Tabanovce ExportMinibus(passenger) 345.00Marijuana

9 28.03.2013 DeveBair Export PMV 10675.00Marijuana10 10.04.2013 Tabanovce Export PMV 12960.00Marijuana11 18.04.2013 St.Naum Import PMV 2955.00Marijuana12 10.05.2013 Kafasan Import PMV 10885.00Marijuana13 12.05.2013 Kafasan Import PMV 7060.00Marijuana14 16/17.05.2013Tabanovce Export PMV 16024.00Marijuana15 06.04.2013 Delcevo Export PMV 6.10Marijuana16 14.06.2013 Tabanovce Export Bus 98090.00Marijuana17 03.08.2013 DeveBair Export PMV 12390.00Marijuana18 10.09.2013 Tabanovce Export PMV 24747.00Marijuana19 09.10.2013 Tabanovce Export PMV 5431.99Heroin20 04.10.2013 Delcevo Import PMV 0.48Marijuana21 01.11.2013 Tabanovce Export PMV 13215.00Marijuana22 26.11.2013 Megitlija Export PMV 30000.00Marijuana23 26.11.2013 Tabanovce Export PMV 6000.00MarijuanaSource:CustomsAdministration.Table9.10.NarcoticsseizuresbyCustomsAdministrationatbordercrossingpoints,2012.

Date Place Import/export Transportation Quantity Type

1 31.01.2012 Customs border point Blace Export Bus 50 l Acetone

8 l Hydrochloric acid

2 29.03.2012 Customs border point Deve Bair Import

Passenger motor vehicle (PMV) 1 270 tablets Methadone

3 09.04.2012 Custom office in Central Post Office Import Delivery by post 52 seeds Cannabis

70 g Magic mushroom – psilocin

 

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4 25.06.2012 Customs border point Blato Import PMV 3 840 g Marijuana

5 05.07.2012 Customs border point Tabanovce Export Bus 9.89 g Heroin

6 17.09.2012 Customs border point Tabanovce Export PMV 5 670 g Heroin

7 17.09.2012 Customs border point Tabanovce Export PMV 6 835 g Marijuana

8 11.10.2012 Customs border point Tabanovce Export Bus 4.5 g Hashish

9 21.10.2012 Customs border point Deve Bair Import PMV 9 445 g Heroin

10 24.10.2012 Customs border point Tabanovce Export PMV 7.3 g Marijuana

11 06.11.2012 Customs border point Blace Import PMV – taxi 5 385 g Marijuana

12 11.11.2012 Customs border point Airport Import Plane 8 tbl Methadone

Source:CustomsAdministration.Tables9.9and9.10showthegeographicaldistributionoftheseizuresin2012and2013.

In 2012 seizures were predominantly made at exit border crossing points, mainlyTabanovce,on theborderwithSerbia,and themaindrugseizedwasmarijuana.The lawenforcement data indicates that the country of originwasAlbania. In one case, in 2013,seizureofa largeamountofmarijuanawasmadeon thebordercrossingpointMegitlija,which is on the border with Greece. The final destination was intended to be theNetherlands,accordingtolawenforcementdata.