Transcript Bridging the gaps - Temple University

Bridging the Gap between Needs and Services
Towards Evidence-based Drug Policy In Poland
Issue: Matching Needs and Services in
Environments of Rapid Change
Injecting drug use, once a “city” problem involving opiates, has moved out into the countryside and now
centers on amphetamine.
“Everybody uses drugs in pubs in Szczecin, but they don’t inject …” -- Regular drug user, occasional injector
“Young people in [small town near Szczecin] inject amphetamine using shared equipment. They are not
afraid of being infected with HIV or Hepatitis because they are convinced that risk of infection is related to
the type of drug – home made heroin -- not to the way of its administration.” – Injection drug user, using for
8 years
Methods: Rapid Policy Assessment and
Response (RPAR)
Department of
Infectious Diseases&
Hepatology Pomeranian
Medical University,
Szczecin
Findings: Changing Patterns of Injection Drug Use
RPAR is an intervention that mobilizes local
knowledge and capacity to fight HIV/AIDS
among sex workers, injection drug users, and
members of other marginalized populations at
the city level. In RPAR, a research team from a
site city works with a Community Action Board
(CAB) to collect three kinds of data: laws and
written policies relevant to health risks in the
target populations; existing data on the
epidemiological situation and the operation of
the criminal justice system; and qualitative
interviews with police, judges, prosecutors, drug
users, sex workers and others who can describe
how the laws are put into practice. The data
collection and interpretation are guided by the
CAB, which develops an action plan and final
report.
The Szczecin RPAR was begun in January, 2005;
research was completed in September and a
final report was released in March, 2006. The
CAB included representatives of law
enforcement (the police, judiciary, prisons), both
public and private drug treatment providers,
health care (physicians, nurses) and social
welfare agencies (Family Support office).
Existing laws and formal policies in ten domains
relevant to drug policy and health (including
harm reduction, drug treatment and prevention)
were collected. To determine how these laws
were being put into practice, three focus groups
were conducted, and the team interviewed 24
people in law enforcement, health care and
social services, as well as 14 IDUs.
Findings: There’s a Poor Match Between Needs and Services
Implications and Recommendations
The Community Action Board and research team discussed
the findings in light of their existing knowledge and
experiences in addressing drug use in the region.
Findings: The Gap is Unfolding Below the Radar
Policy-makers have not been fully aware of the shift, which is not surprising given the
lack of any “early warning” mechanism.
Interviews with service providers indicate that drug abuse prevention and treatment
agencies are unaware of the potentially serious threat and unprepared to address it
effectively. “There is a drug use in our town but people do not inject.” – Therapist from
a small town
In Szczecin, the major focus of drug policy is party or club drugs; injected
amphetamine in the surrounding area is not a worry.
• Drug policy is oriented to large cities; the needs in rural
areas need to be urgently assessed and addressed in terms
of both mandates and resources.
• Patterns of drug use in rural areas are not properly
diagnosed; most policies are based on information from
larger cities where outreach workers collect necessary
data.
• NGOs, the primary providers of outreach services, have
traditionally been city-based and city-focused – they are
not geared to providing services in rural areas and will
require funding assistance to do so.
Findings: The Rise in Rural Amphetamine Injection Poses a Threat to Health
that Should Not Be Treated Lightly
• The Polish National Office for Counteracting Drug Addiction
needs to
• support and be guided by more frequent and rapid
research;
• work with the criminal justice system to promote better
coordination of available treatment services with court
processes and to educate judges and prosecutors about
the benefits and availability of treatment.
Prevention, harm reduction and treatment services needed for an injection-based amphetamine epidemic are
unavailable in the countryside.
Syringe Access
“Young people in small towns are not
able to exchange equipment. There are
no syringe exchange programs. They
have problems to buy the in pharmacies
as well.” – Injection drug user, addicted
for 18 years
“ [Young people] don’t want to go to
pharmacy because they are afraid to be
perceived as drug addicts. Though their
parents and neighbors are all addicted
to alcohol.” – Injection drug user, small
town.
Some pharmacists are reluctant to sell
equipment to drug users. Two IDU
informants reported that pharmacists
will claim to be out of small-bore
needles. “It’s not a problem for old drug
users to inject with a big needle, but it’s
still a problem for young kids” – Rural
IDU, 26 years old.
Meanwhile, the syringe exchange in the
city of Szczecin has seen a decrease in
clients based on ease of access to and
low cost of syringes, as well as a decline
in injecting drug use. “There is no point
in going to the syringe exchange
because we can buy syringes in any
pharmacy.” Occasional IDU, Szczecin.
Syringes cost about $0.10 in a
pharmacy.
Drug Treatment
There are no programs designed for drug addiction in small
towns. “We have relevant therapy offer for drug addicts –
they are treated together with alcohol addicts but they are
counseled individually twice a month.” – Therapist from a
small town. This reflects health policy: “The national health
service does not pay for treatment of drug users here. We
need to treat them together with alcoholics, in the same
group, and try to get our money back. We like people with
multiple dependencies because they are easier to get paid
for.”
The law also plays a role: A “Sobriety Law” from the
Communist Era requires municipalities to provide alcohol
treatment. While the Law on Counteracting Drug Addiction
requires local programs to combat drug abuse (Ch. 4), there
is no mandate to offer treatment.
HIV Testing
Few people in the rural areas are getting tested for HIV.
IDU_4 said that “these young people do not test as they
are sure HIV is not their problem”. She also said it seemed
strange for her as “they believe nobody is infected but how
can they know it if nobody has ever been tested for HIV”
A physician who works at the HIV testing center in
Szczecin confirmed that clients are asked about their place
of residence and the vast majority are from the city.
There are no testing sites in the rural areas.
We know from other countries that amphetamine epidemics can cause serious health
and social problems. There is a risk for rapid spread of bloodborne disease if HIV or
Hepatitis gets into a network of young injectors underserved by prevention, treatment
and harm reduction services.
HIV Diagnoses (Poland)
800
HIV and Hepatitis do
exist in the
population.
HIV in the West
Pomeranian
Voyvodeship has
been stable since
2000 at 4/100 000
(stable since 2000)/
There were 600
diagnosed HIV
infections between
1985 and
31.04.2005. 51%
were attributed to
IDU. 52% of HIV+
people are coinfected with HCV
and 8% with HBV.
• The Szczecin city and regional administrations and NGOs
should work together to further delineate the risk to rural
populations and to institute needed services.
700
Number of new HIV dignoses
Infectious Diseases
Prevention Association
for Western Pomerania
Region
Experience has shown that drug use patterns can
change rapidly, leading to equally dramatic
increases in the spread of bloodborne diseases
like HIV, HBV and HCV. The provision of drug
abuse prevention, harm reduction and treatment
services should be based on evidence of the
current patterns and geographical distribution of
risk. In the course of a Rapid Policy Assessment
and Response Intervention in the city of Szczecin
and surrounding rural areas, we uncovered
evidence that Poland’s programs to prevent and
reduce drug-related harm may not be responsive
to rapidly changing current conditions
Sobeyko J (1), Leszczyszyn-Pynka M (2), Duklas T (7), Parczewski M (2), Bejnarowicz P (1), Chintalova-Dallas R (4), Lazzarini Z (4)(6), Case P (5), Burris S (3)(6).
(1) Infectious Disease Prevention Association of Western Pomerania, (2) Department of Infectious Diseases & Hepatology, Pomeranian Medical University, Szczecin, (3) Temple University Beasley School of Law, (4
University of Connecticut Health Center, (5) Fenway Community Health Center, (6) Center for Law and the Public’s Health at Georgetown and Johns Hopkins Universities, (7) Association for Health Promotion and
Social Risks Prevention “TADA”
600
500
400
300
200
100
0
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Drug use
Other
Poland has a low rate of HIV infection among IDUs,
which is mostly due to the swift introduction of
prevention, harm reduction and treatment programs
for opiate use in early 90s. An equally timely
response is required now.
Unknown
The limitations of our methodology
Zakażenia w irusam i hepatotropow ym i
Incidence
of HBV and HCV (Poland)
10000
9000
8000
7000
6000
HBV
5000
HCV
4000
3000
Our findings are based on interviews from purposively selected
informants and by the information provided by our CAB, supported
where possible by epidemiological statistics and secondary sources.
The data must be viewed with appropriate caution. Given the
experience of rural amphetamine use in other areas, however, and
the potentially rapid spread of bloodborne disease among injectors,
they should be taken seriously and followed up with more sustained
research and intervention work.
2000
1000
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
This research was supported by NIDA/NIH Grant # 5 R01
DA17002-02 PI: LAZZARINI, ZITA . The findings and
conclusions expressed are those of the authors and not
necessarily of NIH, NIDA, or the US government.