drugs, bugs and the things that unite them
Post on 21-Oct-2014
217 views
DESCRIPTION
TRANSCRIPT
Drugs, bugs and the things that unite them.
A former ethnographer's view of
drug policy and public health.
Jean-Paul Grund, PhD
CVO-Addiction Research Center, Utrecht
Department of Epidemiology, Municipal Health Service, The Hague
Summer Institute on Alcohol, Drugs and Addiction, University of
Amsterdam, 15-07-2008, Amsterdam, The Netherlands
The Replacement Speaker’s Dilemma
• My presence today is more determined by the odds
than intent
• What to Present?
• What do I want to convey?
• Who is the audience and what have other speakers
told them?
• “Do something with your past ethnographic work”
(My) Ethnographic Timeline • 1960s Cannabis, psychedelics, opium and speed
• 1970s Street Heroin culture developed in major Dutch cities
– From injecting to chasing
• 1980s House addresses and Cocaine
– 1981: My first practice: the Rotterdam Junkie Union
– Activism, and needle exchange
– 1985: Outreach and “collective” needle exchange
– 1988: Research
– Observations of heroin and cocaine users
– Rituals of regulation
– From needle sharing to drug sharing (Frontloading)
– Rocking up cocaine: cooked cocaine
• 1990s Back to the streets
– Increased repression of until then tolerated house addresses in neighborhoods
– Platform Zero next to Central Railway Station
– From chasing to basing
– From self produced “cooked coke” to “crack”
• 1993 UCONN, USA
• 1995 International Harm Reduction Development Program at OSI/Soros
• 1999 Research: evaluation of needle exchange in CEE & Russia; Roma, drugs & HIV risks
• 2001 UNAIDS Policy Advisor; consultant to Yale Liquid Drugs Study
• 2005 Back to base: research in NL
Today’s Timeline
• A short history of wit & bruin
• 25 years of cocaine smoking: a history of unanticipated
and unintended consequences
• A case of serendipity that illustrates the complex
relationship of drug policy and risk behaviors
• Exercise: Drug injection in Russia
• Drug use and social context in CEE
• On interventions (what to do with all that knowledge)
Problem Drug Use in the Netherlands
• Drugs: (1960s: Amphetamine, Opium); Heroin (1971); Cocaine (± 1980)
• B4 1980: City center street drug markets in Amsterdam (capital), Rotterdam (harbor)…
• After 1980: diffusion into low income neighborhoods & smaller towns; “House Address” market/scenes
• 1990s: Back to the Streets (diffuse street markets)
• 2000s: Mobile Phones (meetings, home delivery)
• Mode of administration: – 1960s: IDU (white, div. background)
– 1970s: shift to smoking (IDUs: white, Chasers: Surinamese, Moroccan)
– 1980 – present: smoking dominates
Mode of Drug Administration
Opiates
Cocaine-Hydrochloride Cocaine-Base
Cocaine Smoking in the Netherlands
Example: Rotterdam
• 1980s: – Cocaine hydrochloride sold at house addresses;
consumed on the spot by smoking (majority) or injecting (small minority)
– Users cooked C-HCL into C-B themselves
– Majority chased cocaine-base
– Part of social interaction within constraints of house address
– Collective use, social ritual in relaxed café-like atmosphere
• 1990s: – 1989: “Smoking over glass,”
– Around 1990: crackdowns on house addresses
– February 1990: first observation of “cooked coke” at Central Railway Station; Lighter & Antenna pipes.
– No one knew where to buy “crack”
– Individual use, quick pull from pipe in (often hostile) public places
Shift to non-IDU use
From self produced “wit” (white)
to “cooked coke” (crack)
• A market environment adjusting to a changing social policy
• Cooked cocaine as an adaptive respons to increased repression (closure of house addresses), resulting in more users on the streets
• Sold for very pragmatic reasons: – "You don't have to prepare it.“
– "It is ready for smoking."
– "It's a gain of time." "It is not so conspicuous when you don't have to prepare before smoking.“
– "You don't have to search for a place to cook the stuff anymore.“
– "You don't need a spoon and ammonia.“
• Pushed cocaine HCL out of the street markets; wiped out preparation ritual;
• result: decreased self-regulation, increased cocaine-related morbidity and problems
Frontloading…
…or the case of the Serendipitous researcher
Frontloading
or
Syringe-Mediated-Drug-Sharing
Definition of Serendipity
• Serendipity (noun): That quality which, through good fortune and sagacity*, allows a person to discover something good while seeking something else.
* Sagacity (noun): personal alertness, awareness, and
understanding; sagacious (adjective): having or showing understanding and the ability to make good judgments; wise
Field work 1988
• Publications on HIV among IDUs in USA
• Needle sharing identified as risk behavior
• Observations at house addresses:
– Few occurrences of needle sharing in Rotterdam
– Drugs often shared, social lubricants
• Both among smokers and injectors
Mode of administration by place of use
Sharing drugs and mode of administration
Drug sharing techniques of IDUs
Field note of Frontloading
“Richard puts the spoon in front of him, empties the heroin package in the spoon and adds some lemon and water. Meanwhile Chris opens two injection swabs and puts them on the rim of the ash-tray. When Richard is ready he nods, which Chris takes as a sign to light the swabs. Richard now holds the spoon above the flame to boil the contents. Chris carefully watches the spoon and says: "I hope it's enough that we feel it." It takes more then 2 minutes to dissolve the heroin. Then Richard puts in the cocaine almost immediately. Cotton is used to make a filter, and Richard draws the cocktail in the syringe barrel.
Richard also divides the cocktail. He puts the needle back on his syringe. Chris gives him his syringe after removing the needle. Richard inserts his needle in Chris' syringe, eyeballs the amount of liquid drug and devides it. He compares each’s content holding the two syringes side by side. In one of them is a little more. That one he gives to Chris. ”
Frontloading injectable drugs
Frontloading • Syringe-Mediated-Drug-Sharing (Frontloading, backloading) is an
important route of HIV and other viral transmission
• The technique of frontloading and similar techniques are known in many countries
• Frontloading observed in the Bronx, Los Angeles, Baltimore, South Florida, Barcelona, Spain, Basel, Bern and Zürich (1993)
• Backloading documented in New York, San Francisco and Denver in the USA, in London, Great Britain and in Barcelona, Spain (1993)
• Frontloading is the most efficient and honest way to split a certain amount of drugs in two or more portions
• "We share everything; social benefit, food, dope, etc."
• Drug Sharing serves both instrumental and symbolic purposes
Synopsis
• Introduction of heroin, 1971; cocaine in 1980
• Emergence of chasing heroin and cocaine and related decrease of IDU
• From chasing to basing
• Syringe-Mediated-Drug-Sharing
• Social context of use: both protection and risk
• Drug use as a social ritual
• Impact of policy (street vs. house address-based markets) on Risk Environment (Rhodes, 2002)
• Drug, Set & Setting (Zinberg, 1982)
Questions, remarks, discussion!
Exercise: Drug Injection in Russia
What do you observe in
the following sequence?
What did you see?
• Write a fieldnote (5 min)
• Discuss in groups of 4-6 (5 min)
• Report back to plenary + discussion (20 min)
Drug Injection in Russia
& Central Eastern Europe
Drug Use Soviet Style: Do It Yourself!
Tradition of Self Preparation of Drugs
“Samagon” Revisited: Tradition of
Self Preparation of IV Drugs
• Poland: “Kompot”
• Czech,Slovak: (“Braun”) “Piko”
• Hungary: “Poppy”
• Russian/FSU: “Cheornaya” “Vint” “Jeff”
Strong Opiate Cocktails,
Containing Codeine,
Morphine, Heroin a.o.
Opium Alkaloids
Strong Psychostimulants:
Methamphetamine
Methcathinone,
Collective Drug
Preparation & Injecting,
Friendship Networks,
& HIV Transmission © Jean-Paul Grund 2001
N. N.
N=236
Pskov
N=205
R-N-D
N=199
St. Petersb.
N = 236
Volgograd
N = 221
Total
N=1,097
30 Days Prior to SEP Use(%)
Never
1-3 Times/Month-Less
Once a Week
2-6 Times a Week
OOnnccee aa DDaayy
More than OOnnccee aa DDaayy //
AAllmmoosstt EEvveerryy DDaayy
9
12
10
31
18
21
5
27
16
31
13
8
13
14
10
32
14
17
4
11
10
29
23
23
15
2
6
20
19
37
9
13
10
29
18
22
Last 30 Days During SEP Use (%)
Never
1-3 Times/Month-Less
Once a Week
2-6 Times a Week
Once a Day
More than Once a Day /
Almost Every Day
14
11
10
26
20
19
11
36
13
31
4
5
20
15
17
28
10
12
7
8
6
26
32
22
20
5
7
19
16
33
14
14
10
26
17
18
1 Totals may not equal 100% due to rounding or missing data.
Frequency of Group Injecting among
Russian Syringe Exchange Participants1
Group Injecting in Last 30 days Before Interview:
• Never Inject in Groups 14%
• Group use is a regular occurrence 61%
– 2 - 6 times a week 26%
– Once to several times a day/almost every day 35%
Clearly, Using in Groups is Normative Behavior
among Russian IDUs.
Group Injecting, Rostov Na Donu
Group Injecting, Rostov Na Donu
Group Injecting, Volgograd
Group Injecting, Volgograd
Injection-Related HIV Risk Behaviors of
Russian Syringe Exchange Participants1
Last 30 days Last 30 days
Before SEP Use B4 Interview
Collective use of Works 82% 73%
S-M-D-S 58% 48%.
The Russian risk environment, results in a very high
prevalence of collective drug paraphernalia use
and Syringe-Mediated-Drug-Sharing
Social Setting of the First Hit, Ukraine
“Who was present at your first injection?”*
Company %
Friends or good acquaintances 80
Person I did not know very well 20
Sexual partner 17
Stranger 7
Alone 5 * More than one answer was possible.
Social Setting of the First Hit , Ukraine
“Who gave you the first injection?” by gender (%)
3
7
3
15
67
3
4
2
32
4
55
1
6
8
13
64
5
5
0 10 20 30 40 50 60 70 80
O ther persons
Running body
Drug dealer
Sexual partner
Self-made
Friend, acquantance
Men Women All
On interventions (what to
do with all that knowledge)
What not to do…
Rely on obsolete treatment
concepts and indiscriminate
law enforcement…
Detoxification at Narcological Dispensary, Kaliningrad
When Substitution Treatment is Unavailable
State Repression vs. Community Integration
IDUs’ Relationships with Law Enforcement
and other Agencies of State Control
“The relations with the police are good, they do a lot of mutual work.”
(Psychologist @ N.D. South Russia)
IDUs’ Relationships with Law Enforcement
IDUs’ Relationships with Law Enforcement
Ignore that drug injecting is a
behavior that cuts across
communities…
Injecting Drug Use is not a Population
Characteristic, but a Behavioral One,
Overlapping Various Vulnerable Populations
• Many Occasional Users
• Sex work
• Gay Community
• National & Ethnic Minorities, e.g. Russians in the
Baltics; Roma throughout CEENIS
• Prisoners
…especially in prison!
HIV prevalence in prisoners,
Russian Federation, 1998-2001
802 2.979 8.789 8.271
706.935
833.071873.587
405.787
113
358
1.006
2.038
0
100.000
200.000
300.000
400.000
500.000
600.000
700.000
800.000
900.000
1.000.000
1998 1999 2000 2001
0
500
1.000
1.500
2.000
2.500
N. HIV+
N. Tested
Rate/100,000
Registered HIV infections,
Baltic states, 1987-2002*
0
200
400
600
800
1000
1200
1400
1600
19871988
19891990
19911992
19931994
19951996
19971998
19992000
20012002
Estonia Latvia Lithuania
Outbreak in Alytus prison camp, August 2002
1 1 8 1 5 4 9 11 1231
5265 72
344
1 1 1 1 2 1 5 3 8 6 7 9
66
18
0
50
100
150
200
250
300
350
400
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
Augu
st 2
002
HIV
AIDS
New HIV & AIDS Cases in Lithuania,
1988 - August 20, 2002
Alytus Prison Camp: 284 Cases
The Solution of the Prison Department &
Lithuanian AIDS Center
What to do?
“The most effective responses to the epidemic
grow out of people’s action within their own
community and national context.”
Handbook for Legislators on HIV/AIDS,
Law and Human Rights (UNAIDS/IPU, 1999)
Substitution Treatment
Outreach Work
Needle Exchange Programs
Secondary Exchange
Slide:Courtesy of S. Strathdee
Not the individual IDUs,
but Networks
• IDU networks organized around exchange of critical commodities (e.g. drugs)
• Secondary syringe distribution taps into existing exchange patterns
• Drugs, HIV travel along natural links in drug using networks
• So should syringes and harm reduction information
Drug Use Characteristics of Russian
Syringe Exchange Participants N = 1,076
N. N.
N = 236
Pskov
N = 201
R-N-D
N = 199
St. Petersb.
N = 221
Volgograd
N = 219
Total
N = 1,076
Age First IDU1 (Mean/SD)
19 (4) 21 (5) 21 (5) 18 (3) 19 (4) 20 (4)
Years Injecting1 (%)
< 3 years
3+ – 6 years
6+ – 10 years
>10 years
22
33
33
12
47
31
10
12
18
22
25
35
43
27
16
14
26
41
26
6
30
32
23
15
Drug Injected1,2
(%)
Homemade opiates
Powder Heroin
Amphetamine
83
47
9
15
53
61
84
5
24
6
96
9
21
90
4
42
59
20
Reported Secondary Exchange (%)
40
46
40
43
48
44
Almost half of Russian Syringe Exchange Participants reported Secondary Exchange (40-48%), whether the program encouraged it or not.
Peer Driven Interventions,
Respondent Driven Sampling
• Peers are rewarded to conduct the same tasks as outreach workers; – Primary incentive for participation in a series of health
education sessions (accent on being taught);
– Secondary incentive for engaging peers in intervention and educating them in the community (accent on teaching);
• Recognizes that peers know best about peers, peers are better to convince peers than professional workers
• Peer driven intervention superior to traditional outreach work intervention in HIV prevention among IDUs – Superior performance on recruitment power, representation,
and in reducing risk behaviours, while being about 30 times less costly.
BEFORE YOU GET
WHATCHA WANT
GOTTA GIVE
THE PEOPLE
WHAT THEY NEED
(Public Enemy)
Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod
Commercial Sex Shop @ AIDS Center in Nizhniy Novgorod
Some quick conclusions
• Drug policy has more impact on drug related harm than on drug use prevalence (eg. MOA)
• Drug users are interested in their health
• Drug users engage in social networks and exercise collective harm reduction action
• Policy makers should better consider intended and unintended consequences of policy and interventions
Photo Credits
Black & White Photographs:
© John Ranard
Color Photographs:
© Jean-Paul Grund
Contact
Jean-Paul Grund
T: +31302381495
W3: drugresearch.nl