Harm Reduction in Substance Use and High-Risk Behaviour

Richard Pates, Diane Riley, Diane Riley, Richard Pates, Diane Riley, Richard Pates

• Publisher: Wiley-Blackwell
• Year: 2012
• Print ISBN: 9781405182973
• eBook ISBN: 9781118343357
• Edition: 1
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

Harm Reduction is a philosophy of public health intended as a progressive alternative to the prohibition of certain potentially dangerous lifestyle choices. Recognising that certain people always have and always will engage in behaviours which carry risks, the aim of harm reduction is to mitigate the potential dangers and health risks associated with those behaviours.

Harm Reduction in Substance Use and High-Risk Behaviour offers a comprehensive exploration of the policy, practice and evidence base of harm reduction. Starting with a history of harm reduction, the book addresses key ethical and legal issues central to the debates and developments in the field. It discusses the full range of psychoactive substances, behaviours and communities with chapters on injecting, dance drugs, stimulant use, tobacco harm reduction, alcohol use and sex work.

Written by an international team of contributors, this text provides an essential panorama of harm reduction in the 21st century for educators and researchers in addiction and public health, postgraduate students and policy makers.

 

Section IV

Regions

Chapter 23

Harm Reduction in Central and Eastern Europe

Tomas Zabransky, Jean Paul Grund, Alisher Latypov, David Otiashvili, Raminta Stuikyte, Otilia Scutelniciuc and Pavlo Smyrnov

Central European Countries

History

In the Central European ex-communist countries, harm reduction approaches have a fairly substantial history, particularly in the western part of former Czechoslovakia – nowadays the Czech Republic. The first programmes began in the Department for Treatment of Addictive Disorders at the General Teaching Hospital in Prague, where the staff provided clean needles to ‘treatment resistant cases of addicted injectors’ in the early 1980s (Zábranský, 2002). The same department was one of the several Czech medical facilities that experimented with provision of medical opioids¹ to patients dependent on a home-made opiate called ‘braun’² who repeatedly relapsed after traditional, abstinence oriented treatments, in the 1970s and 1980s; according to the medical doctors involved, the results were generally positive. Remarkably, these pioneering harm reduction activities were not driven by a threat of HIV and other blood borne infections, but rather by individual health and social welfare concerns (first author's personal communication). The first official substitution treatment programme started in Prague in 1991, when the head physician of the NGO drop-in illegally imported several kilos of methadone hydrochloride from Switzerland, declared it to customs and after several hours of arrest was released and granted (exceptional) permission by the Ministry of Health to provide substitution to severely addicted opioid users in Prague. This permission, however, was not repeated in 1994, and most of the (rather veteran) patients returned to street heroin and ‘braun’ use, with all its dire consequences. Needle exchange programmes have faced no difficulties since their official launch in Czech drop-in centres (1991) and street based programmes (1994), and they have developed into what is seen as services with sufficient coverage today.

In 1988, in response to the only epidemic of HIV in drug users in the region that affected as many as 30% of injectors of ‘kompot ‘³ (by that time the majority of Polish problem drug users (Danziger, 1994), the first documented Polish needle exchange programme was started. MONAR, a faith-based rehabilitation programmes network, launched a needle exchange on a bus which drove through the major open drug scenes of the country. At the end of 1989, after the communist dictatorship was peacefully dismantled, Poland implemented several needle exchange programmes as part of outpatient addiction treatment clinics These programmes faced substantial resistance from conservative parts of society, and – especially in the early 1990s – were seen as rather marginal (see, e.g., Chopin, 1992).

Hungary began experimenting with opiate substitution in 1989⁴ and started its first NSP in 1992 (Csorba et al., 2003). In Slovakia (the eastern part of former Czechoslovakia), the first needle exchange programmes did not appear until the mid-1990s, and opioid substitution treatment was piloted only in the late 1990s (Slabý et al., 2004).

After the fall of the communist regime, the primarily biologically oriented psychiatric (‘narcologic', ‘alcohologic-toxicologic', etc.) medical systems were poorly equipped and lacked the human and other resources to react appropriately to the quickly changing situation with regard to drug availability and patterns of use. The heritage of the Soviet-styled medical system, which focused mainly on repression and coercion, was another burden. The specialised non-governmental organisations (NGOs) took over some of the initiatives in the drugs field in Central Europe and helped to tackle the drug related problems in the region.

In Poland, MONAR, that was created in 1978, became a formal association in 1980 and gradually established itself as the major provider of rehabilitation, prevention and, finally, and somewhat reluctantly, of harm reduction, pushing forward the state-based players in the field. Under the leadership of the UNDP in Poland chaired by Kasia Malinowska-Sempruch a set of ‘cascade training programmes' was created in the mid-1990s and reached hundreds of key professionals in the field in both governmental and non-governmental sectors, and established harm reduction as a key element of drug policy in the country.

In the Czech Republic, the first two NGOs – previously prohibited in the communist regime – appeared in 1991 and were soon followed by many others. These programmes were ambitious in that they did not limit themselves to primary prevention or policy advocacy: instead, they established themselves as providers of many novel services for problem drug users and for drug dependent clients (Kalina, 2007). The ‘Christmas Memorandum' that was sent to the Czech Government in the dawn of the newly established Czech Republic by representatives of major NGOs then active in the drug field (Höschl et al., 1992) urged the Czech government to define its drug policy formally and to establish a National Drug Commission. In a swift response, the first inter-ministerial body of its kind at a high governmental level in the new democracy was established in January 1993. This demonstration of the importance of NGOs for the Czech drug policy ushered in a period of constant involvement of the NGO sector in the drug field. This is currently reflected in the most developed network of NGOs in drug services (including harm reduction) of all post-communist countries.

Unlike Poland and the Czech Republic, the role of NGOs in harm reduction in other CEE countries has been rather limited. The first two NGO-based harm reduction programmes were established in Slovakia only in 1997 (Slabý et al., 2004); the very first OST programme was established in 1999 in the capital city Bratislava, and the second one was established in 2005 in Banska Bystrica, with no further development of the network since then.

In Hungary, the first needle exchange was conducted in 1993 from the ‘drug bus' which was supported by the municipal government of Budapest, but it took five more years before needle exchange programmes ‘went out of the capital' (see Csorba et al., 2003: ch. 4). Opiate substitution treatment began in 1989 in Hungary with the use of codeine and dihydrocodone, methadone was introduced in 1992 (all in one clinic in Budapest), and there has been gradual development of the network outside the capital city since 1995.

Of the four Central European member states of EU, the Czech Republic was the first to explicitly mention harm reduction measures in the National Drug Strategy as its key element; the third Czech National Drug Strategy (for the period 2001–4) placed primary prevention, treatment and resocialisation, law enforcement and harm reduction as the complementary and mutually irreplaceable ‘four pillars of Czech drug policy' and all the subsequent Czech Drug Strategies (2005–9; 2010–18) did so as well.

Hungary lists harm reduction strategies in its framework document to the National Drug Strategy 2001–8 as one of the ‘details of the objectives' (Government of the Republic of Hungary, 2000); remarkably, the Hungarian 2001–8 National Drug Strategy is one of the few National Drug Strategies evaluated externally. The importance of harm reduction for successful anti-drug policy was further strengthened in the subsequent National Drug Strategy (Government of the Republic of Hungary, 2009). This, however, is under constant attack by the new Hungarian government and its further implementation is uncertain at the time of writing this chapter (see, e.g., HCLU, 2011).

Poland was explicit in placing harm reduction as one of five areas of the general aim of the National Programme for Counteracting Drug Addiction 2006–10 (Government of the Republic of Poland, 2006), and again in the subsequent Programme for 2011–16 (Government of the Republic of Poland, 2011) that sets the goal, inter alia, to ‘further develop harm reduction programmes' explicitly.

While the Slovak Republic connects itself rhetorically with the EU Drug Strategy and Drug Action Plans, where harm reduction is made explicit as the essential element of drug policy (European Community, 2005; 2008), none of its strategic drug policy documents does so. Harm reduction is implicit in the national drug policy papers of Slovakia, as well as of several regional and municipal drug strategies. Slovakia mentions in its Anti-Drug Strategy (Government of the Slovak Republic, 2009) the commitment ‘to provide adequate care and assistance to these groups and instruments that prevent the spread of drug abuse-related diseases, HIV and hepatitis in particular' (p. 8) and ‘through targeted prevention, to prevent high-risk behaviour of drug users' (p. 17), merely repeating the weak language of the 2009 CND Political Declaration (Fifty-second Session of the Commission on Narcotic Drugs, 2009), and fails to follow the more concrete language of the two crucial EU documents that were approved by the Slovak Government and other EU member states in 2005 and 2008.

Patterns of Drug Use in the Region and Specific Responses

Czech Republic

The Czech Republic (pop: 10.5 million) is the only European country where the main drug traditionally injected is not opiate(s), but methamphetamine;⁵ this has been the case since the late 1970s. Out of the estimated 37,000 problem drug users, approximately 35,300 (app. 0.5% of the population aged 15–64) are estimated to be current injectors, and two-thirds of them inject primarily methamphetamine (Mrav

ík et al., 2010).

Like other countries in the region except Poland, the HIV rate in the general population and drug users is very low, with around 0.1% in IDUs (accounting for some 7% of all known cases) and far below 0.01% in the general population. The viral hepatitis C is concentrated almost exclusively in the drug injecting population with an estimated prevalence around 23% (Mrav

ík et al., 2010), which puts it to the lowest strata in the EU.

Low-threshold programmes have been developed all over the country with good coverage responding to the regional differences in the extent of the drug problem. Overall, in 2009 there were 95 HR programmes that distributed 4.9 million sterile needles/syringe sets to approximately 30,000 problem drug users in the Czech Republic. This would provide coverage for around 80% of the target population.

After a period of ‘wild substitution' (see above) the OST programmes were standardised by Guidelines from the Ministry of Health in 1998. In 2009, methadone, buprenorphine and buprenorphine/naloxone were used for OST that covered approximately 4,800 patients in no less than 34 medical facilities (Mravcik et al., 2011), accounting for some 25% of the estimated problem opiate users.

The major role of methamphetamine in the problem drug scene made professionals in the field seek specific interventions that would reflect the specific needs of pervitin users. Of those that seem successful the most noteworthy is the distribution of gelatine capsules for oral use of methamphetamine; this protects the veins – and the gastric mucosa – of the users while reportedly making the effect comparable with that of injecting the drug (Mravcik et al., 2011).

Hungary

In Hungary (pop: 10 million), the only available estimates of the number of problem drug users relate to the two-years period of 2007–8, when the estimated number of drug injectors in the country is reported as 6,146 for the given two years, the estimates of heroin of users 3,130 and the number of amphetamine users 27,223 persons (National Focal Point Hungary, 2011). However, there are few details about the methodology of calculation of these numbers and they are thus difficult to interpret.

According to a sentinel study in 676 injecting drug users who were using specialised services in 2009, the seroprevalence of HIV was 0.7%, and viral hepatitis C antibodies were found in 24.4% of the sampled institutionalised population of drug injectors (Bozsonyi et al., 2010). Twenty-one existing low-threshold programmes distributed 392,336 syringes to 2,399 clients in 2009, with a substantial increase from 2005 (105,390 syringes for 959 clients). Ten treatment units provided OST to a total of 992 clients using methadone or buprenorphine/naloxone composite in 2009 (National Focal Point Hungary, 2011).

Poland

With a general population of 38.2 million people, the number of problem drug users was estimated to be as high as 100–125,000 in 2005, of whom 25–27,000 were opioid injectors (Malczewski et al., 2010). The 2008 survey in 13 needle exchange programmes found 78% of the clients had used opioids in 30 days prior to the survey (with 50% reporting heroin ...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Foreword
• List of Figures and Tables
• List of Contributors
• Section I: Background
• Section II: Policy
• Section III: Specific Interventions
• Section IV: Regions
• Section V: Conclusions
• Index