Harm reduction must be recognised an essential public health intervention during crises.

The COVID-19 had a substantial impact on the provision of harm reduction services for people who use drugs globally. These front-line public health interventions serve a population that due to stigma, discrimination and criminalisation, faces barriers to accessing health and social services and are particularly vulnerable to public health crises. Despite this, the pandemic has seen many harm reduction services close, reduce operations or have their funding reduced. Simultaneously, around the world, harm reduction services have been forced to adapt, and in doing so have demonstrated resilience, flexibility and innovation. Governments must recognise the unique abilities of harm reduction services, particularly those led by the community, and identify them as essential health services that must be protected and strengthened in times of crisis.

Women and barriers to harm reduction services: a literature review and initial findings from a qualitative study in Barcelona, Spain.

BACKGROUND: There are an estimated 3.2 million women who inject drugs worldwide, constituting 20% of all people who inject drugs. The limited data that are available suggest that women who inject drugs are at greater risk of HIV and viral hepatitis acquisition than men who inject drugs. This increased vulnerability is a product of a range of environmental, social and individual factors affecting women, which also affect their ability to engage in health promoting services such as harm reduction. METHODS: The researchers undertook a narrative literature review examining access to harm reduction services for women who use drugs in Europe and conducted semi-structured focus groups with women who use drugs and harm reduction and prison health workers in Barcelona, Spain. RESULTS: Women who use drugs face multiple barriers to accessing harm reduction services. These include stigma, both in society in general and from health and harm reduction workers in prisons and in the community; gender-based violence and a lack of services that are equipped to address the interaction between drug use and experiences of violence; criminalisation in the form of legal barriers to access, arrest and harassment from law enforcement, and incarceration; and a lack of services focused on the specific needs of women, notably sexual and reproductive health services and childcare. In Barcelona, participants reported experiencing all these barriers, and that their engagement with the Metzineres harm reduction centre had to some extent mitigated them. However, women continued to experience structural barriers to harm reduction service access. CONCLUSIONS: Women and gender non-conforming people who use drugs face unique barriers to accessing harm reduction services. While services such as Metzineres can be life changing and life affirming for its members, it is incumbent on states to act to address the structural barriers to health faced by women who use drugs.

New psychoactive substance use as a survival strategy in rural marginalised communities in Hungary.

BACKGROUND: New psychoactive substance (NPS) use has become a widespread phenomenon among marginalised communities in Hungary. Since 2010, a growing number of reports in grey literature and anecdotal information among professionals have become available on NPS use among previously unaffected groups, such as people living in rural, socioeconomically deprived communities. In our research, we aimed to explore NPS use among these communities. METHODS: We conducted a mixed method research with convergent parallel design. Data collection took place in 2017 in marginalised communities in villages in two regions in Hungary, where 150 questionnaires were recorded and 50 interviews were conducted with current NPS users. RESULTS: According to the survey results, NPS is very easy to access, synthetic cannabinoid receptor agonist (SCRA) are easily bought in marginalised rural communities (79% found SCRA easy to obtain). Both SCRA and synthetic cathinones are used regularly; 57% of SCRA users and 37% of synthetic cathinone users used the respective substance at least once a week in the past 30 days. Besides NPS, sedative use (without prescription) and alcohol consumption are common among the respondents. 17% of the sample has already injected NPS. The overwhelming majority of the respondents rated regular consumption of NPS as "very dangerous" (SCRA: 75%, synthetic cathinones 72%). NPS users have limited knowledge of consequences and the social and health treatment options available. Most themes in the interviews are associated with surviving stress, crisis and anxiety, as well as the wish to escape from insecurity and chaotic life. Positive effects of substance use (community, joy, energy) are rarely present. CONCLUSION: People who use drugs (PWUD) living in these rural communities face the consequences of the rural risk environment: easy access to NPS, inadequate access to services, poor labour market situation and attributions of marginalised groups, for example disaffiliation. NPS use is not a recreational activity in this population; individuals mainly use NPS to get away from reality, problems, pain, poverty and marginalisation. NPS use is a survival strategy. Effective responses have to address substance use and social integration; we need complex interventions addressing structural factors.

A needle in the haystack--the dire straits of needle exchange in Hungary.

BACKGROUND: The two largest needle exchange programs (NEPs) in Hungary were forced to close down in the second half of 2014 due to extreme political attacks and related lack of government funding. The closures occurred against a background of rapid expansion in Hungary of injectable new psychoactive substances, which are associated with very frequent injecting episodes and syringe sharing. The aim of our analysis was to predict how the overall Hungarian NEP syringe supply was affected by the closures. METHODS: We analyzed all registry data from all NEPs in Hungary for all years of standardized NEP data collection protocols currently in use (2008-2014) concerning 22 949 client enrollments, 9,211 new clients, 228,167 client contacts, 3,160,560 distributed syringes, and 2,077,676 collected syringes. RESULTS: We found that while the combined share of the two now closed NEPs decreased over time, even in their partial year 2014 they still distributed and collected about half of all syringes, and attended to over half of all clients and client contacts in Hungary. The number of distributed syringes per PWID (WHO minimum target = 100) was 81 in 2014 in Hungary, but 39 without the two now closed NEPs. CONCLUSIONS: There is a high probability that the combination of decreased NEP coverage and the increased injection risk of new psychoactive substances may lead in Hungary to a public health disaster similar to the HIV outbreaks in Romania and Greece. This can be avoided only by an immediate change in the attitude of the Hungarian government towards harm reduction.

Veni, vidi, vici: The appearance and dominance of new psychoactive substances among new participants at the largest needle exchange program in Hungary between 2006 and 2014.

BACKGROUND: There has been an almost exponential growth in the number of new psychoactive substances (NPS) on the drug markets in Europe during the past decade. While most users of NPS use them by routes other than injecting, percutaneous use of NPS is associated with very frequent injecting episodes and paraphernalia sharing. METHODS: We assessed to what extent new clients between 2006 and 2014 (N=3680) at Blue Point, Hungary's largest needle exchange program, exhibited a shift during these years in the drugs they primarily injected. RESULTS: Until 2010, 99% of clients injected either heroin or amphetamines. After 2010, however, there was a "replacement chain" of new substances, with one appearing and disappearing after the other: between 2010 and 2014, NPS under five names appeared and gained dominant prevalence (from 0% to 80%), and gradually replaced first the two "traditional" drugs amphetamine and heroin (which diminished to 17% together in 2014) and later each other. We also saw an increase in the proportion of female and older clients. CONCLUSIONS: While our findings are restricted to injected NPS, they suggest that NPS affect the vast majority of the population of people who inject drugs not only in terms of drug use patterns, but maybe also in terms of demographics. Given that over 80% of people who inject drugs use NPS and injecting NPS is associated with increased injecting risks, harm reduction services should be made more available to avoid an epidemic of blood-borne infections.

New cases of HIV among people who inject drugs in Hungary: False alarm or early warning?

Between 2009 and the first quarter of 2014, only one case of HIV (contracted outside Hungary) was detected among PWIDs in Hungary. However, more recent evidence suggests increased sharing of injecting paraphernalia among PWIDs. This is linked to the emergence of new designer drugs that require frequent injection, alongside funding cuts to the Hungarian needle exchange program (NEP) which has reduced access to sterile injecting equipment. During the past five years in Hungary, drug use has become increasingly discussed in moral as opposed to public health terms, and drug consumption has been re-criminalized. The largest NEP in Hungary was closed because of political pressure and government funding for regular HCV/HIV testing/counselling and seroprevalence studies among PWIDs has been stopped. This paper describes the detection of two new cases of HIV infection in PWIDs attending two NEPs in Budapest in May 2014. These new cases may indicate an unfolding HIV outbreak among PWIDs-similar to those reported in Greece and Romania. Yet the question remains: If no further HIV cases are detected, is this because there are no new cases or because there are no testing facilities for PWID?

[Emergence of novel psychoactive substances among clients of a needle exchange program in Budapest, Hungary]. / Új pszichoaktív anyagok megjelenése egy budapesti tucsereprogram kliensei körében.

In this paper the authors summarize experience of a drug service provider with the injecting use of novel psychoactive substances. Among clients of the needle exchange programme of Blue Point Drug Counselling and Outpatient Centre, the authors observed the spread of the novel substances since 2009. The extensive spread of the novel substances caused substantial change in injecting use patterns, thus in the usage of the needle exchange programme. The novel psychoactive substances appeared consecutively, so that this setting gave a unique opportunity to observe and track the emergence of these substances. The authors summarize the characteristics which are important for medical practice (risks, frequent use, severe psychopathological conditions) as well as special risks associated with these substances (substances with unknown composition and effect). They highlight the importance and role of the early warning system, monitoring the online sources of information and testing of samples containing novel psychoactive substances.

Transition to injecting 3,4-methylene-dioxy-pyrovalerone (MDPV) among needle exchange program participants in Hungary.

In 2011, anecdotal data indicated that 3,4-methylene-dioxy-pyrovalerone (MDPV) might become popular among needle exchange program (NEP) clients in Hungary as a possible substitute for formerly used substances such as amphetamines and heroin. The aim of the study reported here was to examine how the emergence of MDPV influenced the choice of the injecting substance among NEP clients. A total of 183 injecting drug users (IDUs) participating in the largest NEP in Budapest agreed to participate in the study and report on their drug use habits. During 2011, remarkable changes occurred in the structure of the primary injected substances. Amphetamine was cited as the primary injected substance by 45.9% of the respondents and MDPV by 48.1%. Close to half of the former amphetamine injectors had switched to MDPV (64 persons, 45.1%) as had 10 (41.7%) of the former heroin injectors and 11 (78.6%) of those using other substances (cocaine and mephedrone). The appearance of MDPV on the illegal drug market had a substantial effect on the drug use patterns of the IDU population. Further research should be conducted to explain the changes, that might include the purity, price and availability of amphetamine and heroin.

[The phenomenon of drug change in the interviews with injecting drug users]. / A drogvaltas jelensege injekcios droghasznalokkal keszult interjukban.

INTRODUCTION: Important part of the studies on drug use deals with drug use transitions because of their public health consequences. Narrating of drug use change states the active decision making in the centre of the process with adding mental states of the participants to the change process. The transitional narratives can be embedded in the social context of "risk environment". METHODS: In the micro-segregation of the Middle-Jozsefvaros (8th district, Budapest) the Blue Point Foundation runs a needle-exchange service in its "Contact Programme". Here the number of registered clients was 2066 in 2010. The study participants were recruited from the clients of this needle-exchange service (from December 2010 to February 2011). The criterion of entering the study sample was injecting mephedrone in the past 30 days. 17 participants were interviewed. The life story interviews had been coded thematically; it had been done until new codes did not carry new meanings. RESULTS: Study participants speak about rapid tolerance and more intensive use of mephedrone after changing their usual drug. This use is more risky because of more frequent injecting. The effect of mephedrone was described like 3,4- Methylenedioxymethamphetamine (MDMA) and cocaine. In the interviews the usual pattern was narrating the positive effects of mephedrone and after this text the narrating of the negative effects. The "risk narrative" and the "enjoyment narrative" were presented separately in the interviews. CONCLUSIONS: Not the expansion of the drug market, but the drug change was observed: earlier drugs to mephedrone or parallel use of mephedrone with earlier drugs (amphetamine and heroin). The purity and availability of heroin and the increase availability of mephedrone may take a role in this process. The absent of drug market expansion was explained by the closeness of the micro-segregation. Results raise attention of the public health consequences of drug change and the proper training of professionals for this change.