Impact of the COVID-19 epidemic on drug markets, substance use patterns, and delivery of harm reduction and

treatment services in Georgia and Ukraine

The study was funded by the 'EU4Monitoring Drugs‘ project funded by the European Commission and implemented by the European

Monitoring Centre for Drugs and Drug Addiction

David Otiashvili, Irma Kirtadze, Tetiana Kiriazova, Kostyantyn Dumchev

Conducted in two EU Eastern Partnership countries, Georgia and Ukraine

Research team

Georgia• David Otiashvili, MD, PhD• Irma Kirtadze, MD, PhD• Ada Beselia, MA• Tamar Mgebrishvili, MA• Irina Vardanashvili, PhD• Nikoloz Otiashvili

Ukraine• Kostyantyn Dumchev, MD, MPH• Tetiana Kiriazova, PhD• Olena Chernova, MPH cand.

Background: COVID-19 pandemic• Similar epidemiological situation

in both countries• Similar response measures:• strict lockdown March-May 2020,

including public transportation closure• partial release starting in May• re-introduction of restrictions in

September0

50100150200250300350400450

01.03.2

020

01.04.2

020

01.05.2

020

01.06.2

020

01.07.2

020

01.08.2

020

01.09.2

020

01.10.2

020

Daily new COVID-19 cases in Georgia

0

2000

4000

6000

8000

10000

12000

14000

16000

3-Mar-

2020

3-Apr-202

0

3-May-

2020

3-Jun-2020

3-Jul-2

020

3-Aug-202

0

3-Sep-2020

3-Oct-20

20

3-Nov-2020

Daily new COVID-19 cases in Ukraine

Background: drug useGeorgia• 52,000 estimated PWID (2.2%

prevalence, population 3.7M)• Opioids: Heroin,

buprenorphine• Stimulant use, including

home-made is prevalent• NPS increasingly more used• HIV prevalence 2.3%

Ukraine• 350,000 estimated PWID (0.8%

prevalence, population ~43M)• Drug scene dominated by opioids,

historically by home-made acetylated opium (‘shirka’), more recently with illicit methadone • Stimulant use fluctuates at ~40% in

the past 30 days among PWID• NPS increasingly more used• HIV prevalence 22.6%

Methods• Prospective cohort study of PWUD (GE N=50, UA N=51) with bi-weekly online questionnaire over 6

months of follow-up• Snowball sampling

• In-depth interviews with PWUD from the cohort• In-depth interviews with key informants (physicians at OAT site and detox clinic, harm reduction

provider, drug user community representative in each country)

Results: Ukraine

Cohort characteristics at baseline

male71%

female29%

Gender

unemployed44%

employed (full or part

time)42%

work and study

2%

retired/social benefits

12%

Employment

Mean age: 38 (range 18-54)All had history of injecting drug use (IDU)Mean duration of IDU: 19 (range 1-34)

Psychoactive substance use history

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Bath saltsInhalantsKetamine

SpicesLSD

SedativesStreet buprenorphine

CocaineMDMA

MyorelaxantsMedical methadone

Medical buprenorphineAntihistaminesAmphetamine

HeroinPervitin, methcatinone

CannabisHomemade opioids

AlcoholIllicit methadone

lifetime 12m use 3m use

Trends in past 14-day drug use

0%

20%

40%

60%

80%

Illicit methadone Medicalmethadone

Medicalbuprenorphine

Amphetamine Cannabis Alcohol Antihistamines

before Mar

Apr07-13

Apr21-27

May05-09

May20-25

Jun02-17

Jun16-21

Jun30-Jul06Jul15-19

Sources of methadone

0%

20%

40%

60%

80%

100%

Dead drops Dealer Intermediary As a gift

Illicit methadone

0%

20%

40%

60%

80%

100%

Dead drops Dealer Intermediary As a gift Pharmacy Clinic

Medical methadone

Illicit methadone (powder or crystals) is produced in clandestine labs and distributed mostly through dead drops (“stashes”).Medical methadone, in this study, refers to medication in tablet form distributed through pharmacies (as opposed to the free government programs). Pharmacies can legally sell the medication by prescription, which can be obtained from licensed private physicians.

Perceptions of changes in access to, price and quality/purity of the drug of choice

0%

20%

40%

60%

80%

100%

Apr07-13

Apr21-27

May05-0

9

May20-2

5

Jun02-1

7

Jun16-2

1

Jun30-J

ul06

Jul15-19

Jul29-Aug

02

Aug12-A

ug19

Aug25-A

ug29

Sep0

8-Sep13

Sep2

3-Sep29

Access

Became easier Did not change Became harder

0%

20%

40%

60%

80%

100%

Apr07-13

Apr21-27

May05-0

9

May20-2

5

Jun02-1

7

Jun16-2

1

Jun30-J

ul06

Jul15-19

Jul29-Aug

02

Aug12-A

ug19

Aug25-A

ug29

Sep0

8-Sep13

Sep2

3-Sep29

Price

Became cheaper Did not change Became more exp.

0%

20%

40%

60%

80%

100%

Apr07-13

Apr21-27

May05-0

9

May20-2

5

Jun02-1

7

Jun16-2

1

Jun30-J

ul06

Jul15-19

Jul29-Aug

02

Aug12-A

ug19

Aug25-A

ug29

Sep0

8-Sep13

Sep2

3-Sep29

Quality/purity

Became better Did not change Became worse

Injection risk behavior and harm reduction

0%

5%

10%

15%

20%

25%

30%

Apr21-27

May05-0

9

Jun02-1

7

Jun16-2

1

Jul15-19

Jul29-Aug

02

Aug12-A

ug19

Aug25-A

ug29

Sep0

8-Sep13

Sep2

3-Sep29

Trends in risk behaviors in the past 2 weeks

Buying a pre-filled syringe Front- back-loading Other tools sharing

Syringe shar ing Did not inject drugs

0%

20%

40%

60%

80%

Bought in apharmacy

Got for freein a

pharmacy

Got in avendingmachine

Got from aHR program

Got from afriend

Got usedsyringe from

friend

Used myown usedsyringes

Sources of syringes in the past 2 weeks

Apr21-27

May05-09

Jun02-17

Jun16-21

Jul15-19

Jul29-Aug02

Aug12-Aug19

Aug25-Aug29

Sep08-Sep13

Sep23-Sep29

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr07-1

3

Apr21-2

7

May05-09

May20-25

Jun02-1

7

Jun16-2

1

Jun30-J

ul06

Jul15

-19

Jul29

-Aug

02

Aug12-A

ug19

Aug25-A

ug29

Sep0

8-Sep

13

Sep2

3-Sep

29

How did access to HARM REDUCTION programs change in the past 2 weeks?

Became easier Did not change Became worse Do not use HR

Harm reduction services

• In the initial phases of the lockdown access was reduced• “Before COVID, I received syringes from NGO; during lockdown, I bought

syringes at the pharmacy”. (Male, 33).

• The programs managed to adapt and resume service provision, increasingly using new modalities (e.g. mobile vans, outreach), and providing sanitizers and face masks.

Access to opioid agonist treatment

0%

20%

40%

60%

80%

Was nottreated for

substance use

Outpatientdetox

Inpatientdetox

OAT

Apr07-13

Apr21-27

May05-09

May20-25

Jun02-17

Jun16-21

Jun30-Jul06

Jul15-19

Jul29-Aug02

Aug12-Aug19

Aug25-Aug29

Sep08-Sep13

Sep23-Sep29

• In the beginning, admission of new patients was reduced• “for the first time since 2013, there was a

waiting list to start OAT” (OAT physician)• Later, admissions resumed with COVID-

19 testing requirement

• The Public Health Center of the MoHissued guidance to allow take-home for all OAT patients in March, up to 90% of patients were transferred (from 60% before lockdown)• in September, “~80% of OAT patients stayed

on the take-home doses, which is significantly more that before the COVID” (OAT physician)

Summary (Ukraine)

• Many PWUD experienced reduced access to their drugs of choice during the initial stage of lockdown, but for the most it was restored after the transportation was re-opened.

• There was a significant decrease in use of illicit methadone (produced by clandestine labs in crystal form) because of access difficulties when restrictions on public gatherings were in place and when transportation was closed.

• Many PWUD switched to medical methadone, obtained by prescription from private physicians or bought from peers/dealers. This did not return to the previous levels, indicating a sustained change in the drug scene

• Harm reduction and OAT programs managed to adapt to the rapidly changing situation and resumed service provision without major interruption. These lessons can be used should the strict lockdown be re-introduced.

Results: Georgia

Results: Cohort study

78%

20%

2%Gender

Male

Female

Nonbinary

54%40%

2% 4% Employment

Employed

Unemployed

Retired/socialbenefits

Student andemployed

Mean age: 38 (range 18-60)

Lifetime and past year prevalence of use of psychoactive substances at baseline (N=50)

0 5 10 15 20 25 30 35 40 45 50

InhalantsHome-made desomorphine

Synthetic cannabinoidsAntihistamines

Synthetic cathinonesOther hallucinogens

Street methadonDiverted medicinal methadone

NbomeKetamine

OpiumSedatives

Diverted medicinal buprenorphineLSD

CocaineStreet buprenorphine

VintMDMA/ecstasy

Psychotroic muscle relaxantsHeroin

Meth/apmhetamineAlcohol

Cannabis

% used

Last year use

Ever use

Proportion of respondents (%) reporting the use of particular drugs in the past 14 days. (Note – sum exceeds 100% due to use of multiple substances by individual participants).

0%

50%

100%

150%

200%

250%

300%

350%

400%

Baselin

e

21-23 April

5-7 May

19-21 M

ay

2-4 June

16-18 Ju

ne

30 Jun -

2 Jul

14 - 16 J

ul

28 - 30 J

ul

11-13 Aug

25-27 Aug

8-10 Sep

t

22-24 Se

pt

Synthetic cathinones

Synthetic cannabinoids

Antihistamines

Sedatives

Psychotroic muscle relaxants

Inhalants

Other hallucinogens

LSD

Ketamine

Nbome

MDMA/ecstasy

Alcohol

Cannabis

Meth/apmhetamine

Vint

Cocaine

Diverted medicinal buprenorphine

Street buprenorphine

Diverted medicinal methadone

Street methadon

Opium

Sources of clean needles/syringes in the past 14 days

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline 21-23April

5-7 May 19-21May

2-4 June 16-18June

30 Jun - 2Jul

14 - 16Jul

28 - 30Jul

11-13Aug

25-27Aug

8-10 Sept 22-24Sept

bought in a pharmacy and got from friend

bought in pharmacy and received from vendingmachinebought in a pharmacy and received from HRC

Other

Found a used syringe/needle on the street

Bought the drug in pre-filled syringe

Used my previously used needles/syringes

Got a used syringe/needle from a friend orpartnerGot it from a friend or partner

Received from a HR program social worker

Received for free from vending machine

Received for free in a pharmacy

Bought in a pharmacy

Perceived ease of access to harm reduction services (%).

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

7-9 April 21-23Ap ril

5-7 May 19-21May

2-4 June 16-18June

30 Ju n -2 Jul

14 - 16Jul

28 - 30Jul

11-13Au g

25-27Au g

8-10Sept

22-24Sept

Do not use HR

Became worse

Did not change

Became easier

2 014

1 055

360

873

3 072

3 268

250 863

332 419

281 904

240 001

0

50 000

100 000

150 000

200 000

250 000

300 000

350 000

400 000

0

500

1 000

1 500

2 000

2 500

3 000

3 500

4 000

January February March April May June July August September

HIV testing (PWID and partners) Syringes distributed

Monthly rates of HIV testing and distribution of sterile syringes to PWID in Georgia in January-September, 2020 (Source – GHRN program data)

Matanga online market

Technology for Matanga online market monitoring • Python with Selenium and Tor for scraping; Golang for export server

• Script is run on the first minute of each hour on a remote server

automatically

• Main assumptions: if a product disappeared from a listing or amount is

reduced – considered sold

• Gathered product data covers Tbilisi, Batumi, Kutaisi, and Anaklia

regions (every region in Georgia that is listed on Matanga)

Results of online market monitoringItem Daily average (min/max.) Total (6 months)

Listings 138 (118/142) 1,312

Vendors 40 (35/55) 124

Transactions 132 (35/882) 22,364

Revenue (USD) 27,083.76 (8,189.65/287,406.22) 4,577,155.05

• 19 types of substances sold• Smallest purchase – $ 1.5 USD• Largest purchase - $ 14,615.00 USD• Cannabis – 48.5% of sales values and 67.1% of transactions

0 500000 1000000 1500000 2000000 2500000

Magic MushroomsDMT

Synthetic cannabinoidMorphine

Gabagamma**Amphetamine

KetamineMephedrone

NZT-52 ***Buprenorphine*

NBOMeLSD

Methamphetaminealpha-PVP

Heroin/SyretsMDMA/Ecstasy

MethadoneCocaine

Cannabis products

Revenue in USD

0 5000 10000 15000 20000

DMTMagic Mushrooms

Synthetic cannabinoidMorphineKetamine

AmphetamineNZT-52 ***

MephedroneGabagamma**

MethamphetamineBuprenorphine*

LSDHeroin/Syrets

alpha-PVPNBOMe

MethadoneMDMA/Ecstasy

CocaineCannabis products

Number of transactions

Monthly transactions for 10 main substances (cannabis excluded in the right)

0

1000

2000

3000

4000

5000

6000

7000

Mar Apr May Jun Jul Aug Sep

Cannabis/Hashish

Nbome

Meth/amphetamine

Methadone

MDMA/Ecstasy

LSD

Heroin/Syrets

Cocaine

Buprenorphine

a-PVP

0

200

400

600

800

1000

1200

1400

1600

1800

Mar Apr May Jun Jul Aug Sep

Nbome

Meth/amphetamine

Methadone

MDMA/Ecstasy

LSD

Heroin/Syrets

Cocaine

Buprenorphine

a-PVP

Monthly revenues from 10 main substances (cannabis excluded in the right)

-

200 000

400 000

600 000

800 000

1 000 000

1 200 000

1 400 000

Mar Apr May Jun Jul Aug Sep

Cannabis/Hashish

Nbome

Meth/amphetamine

Methadone

MDMA/Ecstasy

LSD

Heroin/Syrets

Cocaine

Buprenorphine

a-PVP

-

100 000

200 000

300 000

400 000

500 000

600 000

Mar Apr May Jun Jul Aug Sep

Nbome

Meth/amphetamine

Methadone

MDMA/ecstasy

LSD

Heroin/Syrets

Cocaine

Buprenorphine

a-PVP

Changes in unit cost of substances offered on a Georgian segment of Matanga

0,0

200,0

400,0

600,0

800,0

1000,0

1200,0

a-PVP

Buprenorphine

Cannabis /Hash

ish

Cocaine

Heroin/Sy

rets LSD

Metha/m

phetami…

Methad

one

Nbome

MDMA/Ecstasy

Mar

Apr

May

Jun

Jul

Aug

Sep

Conclusions• Availability of drugs declined• Many PWUD switch to alternative drugs• OAT medication diversion• PWUD would engage in risky behaviors (sharing; obtaining drugs in preloaded syringes),

but resort to safer practices as soon as access to sterile equipment was restored• Some PWUD would benefit as a result of a reduced drug use under the lockdown• Service innovations: mobile vans, self-testing technologies, vending machines, take-

home dosing• Drug market was able to function despite lockdown; adjustment strategies included new

places for dropoffs, home delivery, increased role of a middleman, interractions between PWUD networks, OAT medication diversion

• Mixed results on impact on price and quality