The drug-use situation in the Czech Republic
Author: M. TYRLIK , T. ZUDA , P. BEM , R. POWER
Pages: 89 to 98
Creation Date: 1996/01/01
T. ZUDA National Drug Commission, Department of the Prime Minister, Government of the Czech Republic, Prague, Czech Republic
P. BEM General Secretary, National Drug Commission, Department of the Prime Minister Government of the Czech Republic, Prague, Czech Republic
R. POWER Consultant, United Nations International Drug Control Programme; Senior Lecturer in Medical Sociology, Department of Sexually Transmitted Diseases, University College London, United Kingdom of Great-Britain and Northern Ireland
This article reports on a rapid assessment conducted in the Czech Republic during the second half of 1995. The main aim of the assessment was to describe patterns of illicit drug use, particularly in the capital, Prague. A Rapid Assessment Board was established to oversee the study, and both secondary and original data were collected from a range of sources. Illicit drug use was found to have increased throughout the country in the preceding five years, with amphetamines being the most popular substance. Polydrug use is common. There has been an increase in the use of the so-called "dance drugs", especially lysergic acid diethylamide (LSD), among younger people, and heroin, especially in the main urban areas. Injecting is on the increase, too. There is an urgent need to expand both fixed-site and community-based services.
Not only has the Czech Republic long been ranked among countries with a high alcohol consumption, but the use there of illegal drugs and the abuse of medicines are also not new phenomena: illegal drugs were relatively widespread even in the 1970s and 1980s.
However, one result of the extensive social liberalization that occurred after 1989 has been a marked increase in both the supply of and demand for these substances. The type of substances abused has also changed, and some new drugs have appeared that were previously relatively rare in the country. The opening up of the borders and the significant undermining of police authority that accompanied the change of regime transformed the Czech Republic overnight into a corridor through which drugs could be transported to the West without any effective controls and with minimal risk. This increase in drug shipments through the Czech Republic comes at the same time as the country has become a destination for contraband drugs such as heroin and cocaine'.
The last five years have seen, alongside the growth in imported drugs, a dramatic increase in the domestic production of illegal drugs and their precursors: in particular, the cultivation of cannabis has been joined by the manufacture of amphetamines ("pervitin"). Operations mounted by both the police and the customs authorities in recent years show that drugs are also exported from the Czech Republic.
The greater freedom enjoyed by society after 1989 has brought with it a decline in the authority of State institutions and a rise in non-conformity, particularly among young people, who are almost openly using soft drugs such as marijuana, hashish and LSD. This situation has been accompanied by ambivalence at the political level and confusing and conflicting messages from the media.
The project described here aimed at giving an objective overview of drug-related issues in the Czech Republic. This article is a much abridged and edited version of the report presented to the United Nations International Drug Control Programme (UNDCP) in February 1996 [ 1] .
UNDCP funded a rapid assessment, carried out during the second half of 1995, to investigate illicit drug use in the Czech Republic, particularly in Prague. A Rapid Assessment Board was set up to oversee the project. The Board was made up of experts in the treatment and prevention of drug use and in law enforcement. The Board met every two months to monitor the progress of the research and to facilitate the collection of primary and secondary data. A number of relevant studies were made available to the research team during the course of the study [ 2-11] .
The rapid assessment was conducted under the auspices of the National Drug Commission. The research team comprised Pavel Bém (Coordinator), Mojmir Tyrlík (Research Coordinator), Tomas Zuda (Assistant Research Coordinator) and Robert Power (UNDCP Consultant). A wide range of agencies and institutions was involved in training and in the gathering of data, both from the field and from secondary sources. The data gathering centres were SANANIM in Prague (data collection and training coordination), contact centres at Brno, Usti, Havirov and Olomouc and the Regional Drug Commission at Ostrava. Secondary sources of information were the Public Health Service of the Ministry of Health, the police presidium and academic institutions.
A project of this type would not have been possible without the cooperation of people from awide spectrum of professions who are in daily contact with drug users, one of the most at-risk sectors of the population.
The main aim of the project was to make a rapid assessment of illicit drug use in the Czech Republic. In line with the rapid assessment methodology developed by UNDCP, a strategy was adopted whereby existing data would be collated and original material gathered to fill the gaps. Another aim of the project wag to familiarize researchers with techniques for collecting data on drug use, especially use by those not in contact with treatment services.
The research strategy involved a number of steps:
Establishing the Rapid Assessment Board;
Establishing the research team;
Gathering background epidemiological data and existing research studies;
Devising structured and semi-structured interview schedules;
Training street-based interviewers, about 30 in all (initially in Prague, but later also in Ostrava, Brno, Olomouc, Usti);
Collecting data at the various collaborating research centres from drug users (n=115)
Conducting focus groups to complement the survey data (in Prague and Brno);
Interviewing key persons and experts in cities and regions throughout the Czech Republic to elicit information on regional differences;
Analysing data and comparing them with data from secondary sources ;
Writing a report and disseminating it.
In this section an overview is presented of the main findings of the rapid assessment A comprehensive account can be found in the report to UNDCP [ 1] .
Drug trafficking and drug tourism had become more common since the political changes of 1989. At the time of the study, although it was illegal to supply certain drugs, possession for personal use was permitted. "Pervitin" (amphetamine) was the most popular drug, and over one third of new problem drug users in 1995 were between 15 and 19 years of age.
The Government had taken a number of actions. The National Drug Commission was working on a drug policy for 1995-1998. Anti-drug coordinators had been appointed in 81 districts throughout the Czech Republic, and since the beginning of 1995, a national coordinator of drug epidemiology had been responsible for a nation-wide drug information system.
It was found that primary and secondary drug prevention efforts had increased (although there had in any case been a long tradition of secondary prevention in the Czech Republic), with much attention being given to secondary school pupils. In 1994, an intensive media campaign had warned the public against the potential dangers of drug use. Moreover, changes in health insurance since the early 1990s had led to the privatization of many drug treatment clinics, with an accompanying increase in non- governmental organization activity and low-threshold drop-in centres.
Drop-in centres had pioneered needle and syringe exchange programmes, mainly in Prague but also in Brno, Olomouc, Usti and Labem. Some drop-in centres had also launched outreach services. Workers at the drop-in centres were well informed about the local drug scene. There were, however, no methadone programmes in the Czech Republic, although negotiations were under way to introduce pilot schemes.
Original data collected specifically for the rapid assessment were supplemented by data from a number of secondary sources to assess the nature and extent of drug use. All measures showed a considerable increase in drug use in the five preceding years. Polydrug use was common, with marijuana, "pervitin", heroin, LSD and "ecstasy" being the most popular. More dm 20 per cent of boys in secondary school and 15 per cent of girls have used drugs, with higher rates in Prague and large cities. Research suggests that it is a matter of status among young people to have experienced drug use, but not for such use to have gone out of control.
It was found that more than one third of long-term amphetamine or heroin users had not completed their secondary education and that the number of heroin users was increasing rapidly. Heroin use was concentrated in Prague and in northern and western Bohemia, while amphetamines were used throughout the country and solvents were common, mainly outside of Prague. Cocaine and crack were rare among students, but LSD was popular, especially at discothèques.
The Institute of Information and Statistics of the Czech Republic (UZIS) collects statistics from both public and private health-care institutions. One study of drug users seeking help showed that for 36 per cent of clients the primary drug was "pervitin", for 21 per cent, it was opioids and for 10 per cent solvents. Twice as many men as women had sought help, and 40 per cent were 19 years or younger.
This portion of the rapid assessment focused on drug users who had not sought help. A sample of 115 regular drug users was recruited in Prague, Brno and Olomouc and in northern Bohemia and northern Moravia. The average age of the sample was 21 years (median: 21 for men; 17 for women); 43 per cent were unemployed, 21 per cent employed and 32 per cent students. Forty per cent had a permanent sex partner, with women more likely than men to be in a relationship with another drug user and to have begun to use drugs after developing such a relationship. Fifty per cent cited amphetamines as their drug of choice, with 41 per cent citing it as a secondary drug. Other secondary drugs were heroin (41 per cent), LSD (38 per cent), alcohol (36 per cent) and hypnotics (20 per cent).
The overall drug scene had changed: whereas once they had been home-based, drug dealing and consumption were now taking place at a range of public and semi- public venues, although there are regional differences, with public drug use most pronounced in Prague. It was learned that amphetamine users tended to use their drugs in the "drug flat" where they had been produced.
There were a number of findings on drug dealing. Networks of drug dealers had begun to overlap, and former small-scale amphetamine producers were becoming involved with organized criminal syndicates. Users said their most frequent source of drugs was a friend, and most of them relied on the drug dealer to ensure quality. Some drug users were also small-scale drug dealers.
Drug use and drug injecting most often took place in the company of others, it was reported. Only 40 per cent of injectors always injected themselves, and they had often been initiated into injecting by another person.
The majority of drug injectors had shared injecting equipment at some time, with only 35 per cent claiming never to have done so. The youngest injectors were most likely to share injecting equipment. Overall, 17 per cent of the sample said they would accept a used syringe from anyone and 20 per cent said they would accept one from a good friend. Intoxication was the main reason given for sharing needles and syringes, and women were most likely to share needles and syringes with a sex partner. However, when project results were compared with the results of an earlier study, it was seen that more injectors (25 per cent vs 10 per cent earlier) always used new injecting equipment.
Only 5 per cent used boiling water to sterilize injecting equipment, 4 per cent used disinfectant, 42 per cent rinsed in water and 24 per cent did nothing. Needles and syringes were obtained from pharmacies and exchange programmes and (most often) as a gift from friends, but they were also scavenged from hospital dumps and other high-risk sources. Places where there were syringe exchange schemes reported a lower frequency of needle and syringe sharing.
It was found that 50 per cent of injectors had been tested for HIV compared with 18 per cent of non-injectors. There were low levels of HIV positive results, but high levels of sexual activity among injectors. Only 14 per cent reported regular condom use with casual partners, and 21 per cent reported selling sex for money or drugs.
Focus groups were conducted in Prague and Brno to complement the survey data and data from secondary sources.
The salient information gathered in Prague may be summarized as follows:
Young people (13-16-year-olds) were perceived to be at greatest risk of drug use and injecting;
Drugs were widely available to experimenters;
Shortages of drugs led to switching, typically from amphetamines to heroin;
More layers in the drug distribution network had led to a greater adulteration of the product and poorer quality, as well as substitution by producers, e.g. small quantities of heroin in place of LSD;
Drug supply varied, especially the supply of amphetamines, which were mostly available on weekends;
The main health problems cited related to life on the streets and fear of overdose;
Drop-in centres were the preferred places at which to seek help, but there were fears about loss of anonymity;
A clear link existed between clubs, drug distribution and drug use;
Ethnic minorities were involved in drug dealing;
There was evidence that methadone had appeared on the black market.
At Brno, some of the findings were the same as in Prague, others not:
Teenagers were perceived to be at greatest risk of drug use and injecting;
New ways of marketing drugs had changed the nature of the drug scene, which had become less cooperative;
Amphetamines and toluene were the most common drugs;
LSD was available in clubs, but neither heroin nor cocaine was widely available or used;
Ephedrine, the raw material for amphetamine production, was smuggled from Poland or Hungary;
There was a general mistrust of helping agencies, but drop-in centres were seen as attractive;
Some Brno drug users travelled occasionally to Prague for heroin and for amphetamines when they were in short supply;
Certain minority gangs often attacked dealers and robbed them of drugs and money. Child members of this minority were frequent users of solvents.
While there is indeed regional variation in drug use, drug problems exist throughout the Czech Republic, and many drug users have no contact with established services. The main concentrations of problem drug use are Prague, northern Bohemia and northern Moravia. Drug users often travel to Prague to get medical care or to use drop-in centres, but they also buy drugs to take back to their hometowns. Moreover, Prague offers migrants work opportunities and acceptance among drug user groups.
Amphetamines are the most popular drug in Moravia, in the eastern part of the country. In northern Moravia, Ostrava and Havirov are the main centres of drug use, and them are large numbers of solvent sniffers. Amphetmines and heroin are injected in northern Moravia, but no needle and syringe exchange schemes exist. The drug scene in central Moravia is more hidden than in places such as Prague.
In the northwestern part of the country, heroin is more common, with northern Bohemia the central distribution point and considered to be a region at great risk. Increased needle-sharing is reported there, with few opportunities to obtain sterile injecting equipment. In western Bohemia (Plzen Karlovy Vary) there is an established network of drug use and distribution, especially amphetamines.
Many people experiment with drugs but do not go on to develop drug use problems. Others fail to seek help until a range of psychological and social problems occur, including problems with parents, health, school, friends, work and sex partners. Heroin users particularly mentioned financial problems, and injectors reported more problems than non-injectors. Many drug users did not have sufficient documentation to permit gainful employment. Two thirds of drug users expressed a desire for some kind of help; only 10 per cent focused on abstention.
Needle and syringe exchange programmes have encouraged contact with drug services. Drop-in centres are valuable low-threshold contact points because many drug users first seek help from them. Peer education, an approach in which drug users provide information to each other, could be an appropriate way to publicize services.
The initiative generated by the rapid assessment should be sustained. The members of the Rapid Assessment Board should continue to meet, albeit under a new name, and to act as focal point for the collation of information on drug use. They should strive to incorporate all organizations interested in and involved in collecting data on drug use in the Czech Republic. Such a group would ensure the ongoing monitoring of the drug use situation using both quantitative and qualitative means. The 81 anti-drug coordinators should continue to collect data. Not only would such data form the basis of a database covering the country as a whole, it could also be used to develop services tailored to local needs and local drug profiles.
All indicators point to a major risk of drug problems amongst the young, and both primary and secondary drug prevention interventions should be focused on this sector of society. Peer education programmes should be initiated to provide clear and non- sensational information to young people on the dangers of drug use.
Drug services are inadequate in many parts of the Czech Republic, and serious attention needs to be paid to providing a broad network of treatment options throughout the country, including low-threshold services, such as drop-in centres and easy-access needle and syringe exchange programmes. These low-threshold services should be able to refer clients to detoxification and rehabilitation centres, as experience shows that those not already in contact with services are likely to approach a drop-in centre or a needle exchange programme as the first step in seeking help.
Outreach services, too, need to be fully developed in the Czech Republic to allow making contact with the hidden population of drug users, especially in those areas outside the main cities where only limited services are being provided. Outreach services can also promote risk reduction to existing drug users and provide needles and syringes to injectors.
Workers in drop-in centres and outreach programmes develop an excellent first- hand knowledge of the local drug scene. The outreach approach that was initiated during the rapid assessment should be nurtured and encouraged, allowing such knowledge to be collected routinely and passed on to the Rapid Assessment Board.
Where the level of heroin use is high, consideration should be given to pilot methadone programmes. These should operate in line with international research, which suggests that doses lower than 50 mg are ineffectual in retaining patients and, amongst injectors, in reducing injecting behaviour.
Treatment programmes also need to focus on counselling and primary health care for other target groups, particularly amphetamine and solvent users.
The research confirmed that high-risk injecting practices led to HIV and other infectious diseases, notably hepatitis C. Outreach workers and peer counsellors should be used to identify high-risk activities. Interventions should then focus on reducing the risk, not only by providing sterile needles, syringes and other drug-injecting paraphernalia such as filters and water, but also by changing behaviour. This win mean working towards a situation whereby it is no longer acceptable in drug-using circles for needle and syringes to be shared. Former drug users and other respected figures in the drug user communities can be used to promote healthier lifestyles. Rates of HIV infection among drug users are currently low. To keep them low, vigorous risk reduction strategies (notably easy access to sterile injecting equipment) should be put in place immediately throughout the Czech Republic.
To protect public health in general, measures should be taken to ensure the adequate disposal of used injecting equipment. This should include easy-access disposal bins, along with smaller disposal containers provided to individual drug injectors. Small-scale drug dealers might be used to assist in this matter.
Attention should also focus on the sexual activity of drug users, and the use of condoms in heterosexual and homosexual sexual intercourse should be encouraged.
Special services need to be developed for ethnic minorities and other groups who have their own cultural and linguistic needs. Also, the particular needs of female drug users and women in sexual relations with male drug users should be given priority.
To provide an array of services to deal with the wide range of problems that drug users bring to helping agencies, multi-disciplinary teams are needed that include medical staff, psychologists and social workers. People working in the drugs field need comprehensive training to ensure a consistent approach and to bring them up to date on treatment ideas and the philosophy and practice of harm minimization. The police will need similar training. The fact that personal possession has been decriminalized means that drug users can be contacted by outreach workers at known congregation sites without fearing arrest. However expedient this may be, measures may nonetheless be needed to reduce the level of street-dealing.
The rapid assessment has made clear the need to develop drug services in the Czech Republic. These services should be widely diffused geographically, they should be broad-based, they should be tailored to the needs of the target groups, and they should offer a mix of primary and secondary prevention, as well as harm minimization.
M. Tyrlík and others, Rapid Assessment of the Drug Use situation in the Czech Republic (Prague, National Drug Commission, February 1996).02
Ministry of Health, Public Health Service, "Epidemio-sociological study concerning drug use among secondary school students in the Czech Republic", unpublished manuscript.03
L. Csémy, "European project concerning drug and alcohol use among young people-secondary schools and vocational education centres", unpublished research report for National Centre of Health Promotion.04
L. Csémy, "Prevalence of use of habit-forming substances among the Czech population- general population", unpublished research report for National Centre of Health Promotion.05
Ministry of Health, Public Health Service, "Information about, attitudes towards and experience of habit-forming substances among first-year students at Palacké University in Olomouc", 1995.06
Ministry of Health Public Health Service, "Prevalence study of problem users of addictive substances in the Czech Republic", 1994.07
Ministry of Health, Public Health Service, "Incidence of problem drug users 1st - 3rd quarter 1995 ", 1995.08
Ministry of Health, Institute of Information and Statistics, Official Health Statistics 1995.09
M. Tylík, Social and psychological aspects of long-term drug use in the Czech republic", FILIA, 1995.10
Ministry of Health, Public Health Service, "Research on drug users carried out in the field specifically for the Rapid Assessment", annual report, 1995.11
Kamil Kalina, "Drugs from all sides", FILIA, 1995.