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

Mode of Drug

Administration

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

E: jpgrund@drugresearch.nl

W3: drugresearch.nl