Policing, massive street drug testing and poly-substance use chaos in Georgia – a policy case study

The drug control regime in Georgia has been focusing primarily on law enforcement
measures to target supply and availability of particular drugs and to reduce demand
through imposing harsh punishment on drug users. There is a lack of evidence available
suggesting any positive results in terms of reduction in the prevalence of problem
drug use and/or its negative consequences. Reactive in its nature, the simplistic,
repressive response heavily relied on consumer sanctions and stimulated shifts in
drug markets and users behavior. In most cases these shifts were associated with the
introduction and use of new toxic preparations and subsequent harm to the physical
and mental health of individuals.

Old markets limited – new markets explored

Efforts to limit the availability of particular drugs almost uniformly lead to an
increase in use of other drugs, development of new sources of supply and/or production
of new substances 28]. The heroin shortage in Australia in 2000–2001 provided a useful example of drug
market shock in which the abrupt reduction in supply of heroin, with consequent increase
in its price and decrease in purity and availability, resulted in a clear reduction
in heroin use and increase in use of other drugs. The majority of heroin users reported
a compensatory increase in consumption of cocaine, cannabis, benzodiazepines and methamphetamines
3], 29]–31]. Another example was the spread of small-scale manufacturing of methamphetamine-like
preparations utilizing over the counter cold medications and other more easily obtained
chemicals, in response to the US government’s attempt to halt the illegal manufacturing
of methamphetamine by regulating the sale and distribution of the precursor chemicals
in the 1980’s. As stated by Cunningham and Liu, “the end result was an explosion in
rural manufacturing and dangerous explosions of small kitchen labs used by meth addicts
to cook up their own supplies of speed” 32].

Where illicit drug markets and distribution schemes are concerned, both traditional
and novel control measures have been met with rapid countermeasures and technological
innovations 33]–35]. Recently, the rapid increase in use of new psychoactive substances (NPS) has brought
a global change in drug markets, with the number of NPS already exceeding the number
of psychoactive substances controlled at the international level 36], 37]. More than this, the Internet has shown to make an impact on the drug markets dramatically
and has allowed information on drug use and production to spread rapidly, effectively
facilitating the diffusion of new trends 6], 38].

Consistent with these findings, our research suggests that Georgian drug markets and
drug users have shown a considerable capacity and innovation to adapt to new regulatory
measures and increased scrutiny by law enforcement. Reduction in availability of traditional
drugs led to the exploration and rapid growth in use of new drugs, mostly domestically
manufactured substances. Describing and understanding organized drug distribution
networks falls beyond the scope of this report. However, available data might suggest
that these networks have been remarkably overshadowed by the rapid emergence of freelance
distribution of Subutex® in mid-2000s (smuggling from Europe by leisure or business
travellers 14]), as well as by user-driven kitchen production of injection preparations. It is to
be investigated to what extent the Internet (for example, online recipes for self-production)
has been influencing the development of Georgian drug markets.

This policy review provides unique example of a small country in which multiple specific
policy interventions resulted in prompt and dramatic changes in drug consumption patterns.
The scale and dynamics of these changes were impressive. Within 1–2 years, introduction
and spread of new injection drugs/preparations, and a similarly rapid decline in consumption
of these preparations evidently in response to targeted enforcement measures, only
to give way to new substances. As argued in the following sections, the ultimate result
of these changes did not seem to have led to any improvement in individual or public
health. Rather, vice versa. Drug users switched to more toxic preparations and exercised
more risky behaviour. However, the sensitivity and responsiveness of market players,
seemingly very effective and rapid diffusion of information and new trends in the
Georgian drug user setting can, and should, provide a window of opportunity (and become
a focus of future research endeavours) for innovative approaches to educate and support
behavioural changes aiming at reduction of negative consequences of substance use.

Drivers behind changes in patterns of drug consumption

Development in substance use patterns is driven by a complex set of factors and socio-economic
context. In many cases, drug use patterns in Georgia were largely shaped by policy
response and law enforcement practices implemented at particular periods of time.
Among others, these changes were driven by both consumers’ attempts to substitute
the traditional drug of their choice and to make drug use less visible, so that risk
of arrest would be reduced. In our previous report we suggested that less visible
external signs of intoxication and absence of buprenorphine in the police drug testing
kits played an important role in the rapid spread of Subutex® consumption in mid-2000s
15]. This lack of detectability obviously contributed to the spread of home-made ATS
injection as well. As in case with buprenorphine, standard urine testing kits used
by police did not include amphetamine and methamphetamine (at least at the initial
stages), thus allowing users of vint and jeff to pass testing undetected. The same goes for other experimental drugs like Coaxil®,
Lyrica®, and Tropicamid®. In addition, the risk of arrest was reduced since all the
ingredients for kitchen production were obtained via pharmacy and convenience stores
and there was no need to engage with drug dealers. Importantly, new injection preparations
were remarkably cheaper – $5-7 per single dose of vint, jeff or krokodil, compared to $50-100 per single dose of heroin or buprenorphine.

Apart from directly influencing the supply of illicit drugs, law enforcement seeks
to reduce the demand by making drugs expensive, hard to obtain and/or too risky to
engage with. In Georgia politicians have argued that law enforcement (massive drug
testing) reduces the demand by increasing the probability to get punished and thus
coerces drug users to stop using drugs. In reality, the risk of detection is fairly
limited and the improvement of detection rates is unrealistically expensive 28]. In the United States, cannabis users had a tiny 1 in 3,000 risk of being arrested
for any given incident of cannabis use 4]. Simple calculations (45,000 problem injection users; roughly one injection per day;
20,000 positive results of the rapid urine toxicological testing in 2013 – see Fig. 4) give us about 1 in 1,000 risk of being arrested for any given incidence of injection
drug use in Georgia. To be more accurate, this risk is even lower since 20,000 positive
test results include non-injection/non-problem drug use as well, mainly marijuana.
Obviously, this risk is low enough to support the assumption that it should drive
the drug user’s decision to stop using. However low the risks of detection and arrest
may be, it seems that Georgian drug consumers still did not ignore those risks. We
believe that severe and grossly disproportionate punishments for possession/use of
illicit substances involving long-term incarceration were important contributors to
that. For example, possession of heroin in the amount of more than 1 gram, regardless
of the purpose, is punished with 8 to 20 years of imprisonment or lifetime term (Art.
260 of the Penal Code of Georgia (III)). According to the same code, rape is punished
with 4–6 years of imprisonment (Art. 137 of the Penal Code of Georgia) and murder
is punished with 7–15 years in prison (Article 108 of the Penal Code of Georgia) 39]. Such harsh measures combined with large and frequent police engagement with drug
users dramatically reduced the public visibility of people “under the influence” of
psychoactive substances, driving drug users further underground and making their engagement
with prevention and treatment services extremely difficult.

New drugs – new harms

In an Australian study that described an increase in consumption of cocaine and other
stimulants as a response to heroin shortage, Topp and co-authors suggested that “given
the differential harms associated with the use of stimulants and opiates, this possibility
has grave implications for Australia, where the intervention and treatment system
is designed primarily to accommodate opiate use and dependence” 29]. On a positive note, reduction in overdose deaths and a possible reduction in injection
drug use and hepatitis C infections were suggested to be potential public health benefits
as a result of the Australian heroin shortage 3]. Switching to new drugs in Georgia was in many cases associated with increased risks
for blood-borne infections and other harms often related to the toxic nature of ingredients
used for preparation of self-manufactured injection solutions. Buprenorphine, home-made
stimulants and home-made opioids all were obtained, processed and used in a way that
required a group of injectors to collaborate. This was related to either collection
of money for expensive 8 mg buprenorphine tablet, to be later divided and injected
by, usually, four individuals, or to predetermined division of functions/labor (money,
procurement of precursors, cooking) among group members in case of preparation of
home-made stimulants and opioids 11]. In all these instances injection happened within a group of 3–5 drug injectors with
apparently little direct sharing, but frequent indirect sharing via common container,
cotton filters, and large volume syringe for division (front or back loading) of the
produced substance 9], 40].

Addiction clinics and harm reduction programs reported numerous physical, neurological
and psychiatric complications among consumers of home-made preparations, both stimulants
and opioids, which were apparently linked to the toxicity of precursors used for processing
– phosphorus, iodine, potassium permanganate, gasoline, strong acids and so on 41]. Soft tissue damages, necrosis, gangrene, osteomalacia and other severe impairments
have been reported elsewhere in connection to injection use of krokodil and self-produced
ATS 42]–44]. Harm reduction services in Georgia have also reported increased demand for naloxone
among krokodil injectors. Elevated risk of overdose was apparently associated with
difficulties in titration and fluctuating quality/potency of self-manufactured krokodil
11].

Attempts to self-medicate and substitute traditional drugs of abuse have resulted
in majority of drug injectors switching to unstructured poly-substance use. Dependent
drug users consumed whatever intoxicants were available at the moment, often in combination,
aiming to mimic their drug of choice and/or to increase the potency and prolong effects.
Nine out of ten respondents in one survey (clients of needle and syringe exchange
programmes) reported injecting at least two drugs, and two-thirds reported injecting
three or more drugs during the last month 15]. This has apparently resulted in the rise in the number of overdose since most overdoses
occur among individuals who consume multiple substances 45]. However, overdose cases are not properly documented in Georgia and we are lacking
the data to support this assumption.

Legal and ethical aspects of massive street drug testing

In Georgia, tens of thousands of people are subject to administrative and criminal
proceedings (including sentencing to prison terms) as a consequence of positive rapid
immunoassay test results. To the best of our knowledge, no other jurisdiction uses
the results of rapid screening as irrecusably final evidence of drug use because of
the issues related to the often-low specificity of the tests, cross-reactivity, and
the stability of these devices (their ability to resist certain conditions, such as
temperature and humidity). Elsewhere, these results are considered preliminary and
indicative, and advanced confirmatory laboratory tests are required for legal proceedings
both in criminal justice and workplace settings 46]–49]. In Georgia, the results of these rapid tests are used as one single source of evidence
in court, leading to heavy fines or imprisonment. We believe that this practice contradicts
established international standards for a fair trial where sufficient evidence should
be required for conviction beyond reasonable doubt of proof 50]. However, it is obvious that confirmatory testing of those who tested positive using
initial on-site tests would increase the cost and expenditures of the testing intervention
immensely.

We estimated that 1 in 20 men residing in the country was tested for drugs in 2013
(60,000 testing episodes among 1.4 mil men aged 15–64 51] leaving in Georgia). Punitive measures, including massive street drug testing, that
have no analogue in developed countries did not result in any measurable reduction
in drug use in Georgia. Instead, such measures caused the harmful criminalization
of thousands of otherwise law-abiding individuals. Importantly, these punitive measures
had little or no influence on individual decisions to cease or to continue using drugs.
Our earlier report showed that 89 % of individuals punished for drug use (as per positive
drug test) returned to drugs immediately after the punishment, and 11 % did so within
few months following the penalty 12]. Punishment did result in a change in user behaviour – study participants reported
adapting variety of strategies to avoid being identified by police (injecting alone,
injecting and staying at home, avoiding traveling by taxi and so on).

Finally, it is reasonable to state that massive drug testing, with the majority of
the test results being negative, raises an ethical question. Subjecting tens of thousands
of people to humiliating and lengthy drug-testing procedure infringes upon the dignity
of citizens and undermines the public perception of a just and sound policy. Figure 5 presents a schematic description of drug policy interventions and relevant health
and social implications in Georgia.

Fig. 5. Policy interventions, evolving drug scene and implications

Limitations

As with any research, our review has limitations.

Literature review

In our analysis we focused on associations between specific law enforcement interventions
and changes in illicit drug markets and substance use patterns. However, shifts in
drug trends are obviously not only a function of enforcement. Drug markets are responsive
to different political, socio-economic and cultural forces. Nevertheless, analysing
those factors, whatever the importance, was beyond the scope of current review. Secondly,
due to lack or complete absence of data, we were unable to assess the effect of drug
enforcement measures on initiation of drug use by new users.

Secondary analysis of drug use data

We believe that the reliability of drug use data analysed for this report was satisfactory.
Differences in the prevalence of current use of specific drugs in two samples might
suggest that these were somehow different drug using populations with distinct characteristics
and behaviours. It is hard to estimate to what extend samples for two surveys overlap.
Between 3.5 % (in Tbilisi) and 44 % (in Gori) of BBSS respondents reported receiving
services from needle-syringe programs. Importantly, both surveys reported very similar
trends in injection drug use over the years, which might suggest that these data correctly
reflect availability and/or preferability of particular injection drugs by significant
portion of Georgian PWID at specific periods of time.

Our general concerns relate to the overall fragmented character and limited scope
of the data available in the country. Absence of comprehensive drug monitoring system
in Georgia that would provide valid, relevant and continuous data was the major limitation.
In order to measure changes in drug consumption, we focused on four major injection
substances and relied on data provided by GHRN annual client survey and periodic BBSS.
Supposedly, both surveys deal with problematic drug users, whom of which do not necessarily
represent the entire substance-using population in the country. These problematic
poly-substance users can respond to changes in a specific way, simply saying – consume
whatever is available and rapidly switch to new drugs. Other groups (recreational,
experimental users) may have responded differently to the changes in the legal environment,
but there are no data to explore that. For example, as is the case with other countries
36], it is possible that new psychoactive substances, in fact, attracted new cohorts
of users and they exercised responses and behaviours different from those of systematic
injection users of drugs. Again, given the data available, we were unable to examine
trends in NPS consumption and intentionally focused on four most prevalent injection
drugs. Furthermore, since treatment options in Georgia are fairly limited and often
subject to patient’s ability to cover the cost of the service, it was hard to measure
whether reduction in supply/availability of specific drugs correlated with increased
utilization of treatment. This is particularly true for prohibitively expensive drug
free treatment and, to a lesser extent, to more affordable opioid substitution treatment.
It is hard to suggest whether the visible increase in treatment episodes was a function
of raising demand, or if it only reflected the persistently unsatisfied high demand
for substance use treatment in the context of inadequate (maximum 10 %) coverage.

Finally, due to the lack of data, we did not discuss the price and purity of illicit
drugs and did not cover the numbers of negative health and social consequences, including
overdose death, morbidity due to toxic nature of home-produced injection preparations,
criminal justice costs, social marginalization of users and their families. Some economic
implications of massive street drug testing were reported earlier 12].