Injecting drug users

There are estimated to be 13,800 IDUs in Estonia and the majority are poly-drug users who are injecting amphetamines, with up to 55% injecting more than one substance. HIV was high in 2001 and has been going down every year. The rate stabilised in 2005 and the virus is becoming more sexually transmitted with more than 50% of new cases being sexually transmitted to partners of IDUs. A report by the Ministry of Social Affairs (Uusküla et al.

2006) on HIV and risk behaviour among injecting drug users in Tallinn and Kohtla-Järve has shown that Estonia has the most rapidly expanding HIV/AIDS epidemic, with the highest reported incidence and estimated prevalence of HIV (1.5%) in the European Region fuelled by injection drug use. Since the beginning of the HIV epidemic in Estonia in 2000:

The total number of registered HIV infection cases have been 4,662 (as of May 2005), of which 34% (N=1602) have been reported among the residents of Tallinn, and 20% (N=949) have been residents of Kohtla-Järve. Based on this data, HIV prevalence is 0.8% among the adult population (aged 15–49) of Tallinn and 4.2 % in Kohtla-Järve (Uusküla et al. 2006).

The report on HIV and risk behaviours among injecting drug users in Tallinn and Kohtla-Järve (Uusküla et al. 2006) was based on a sample of 450 injecting drug users from these two cities (Table 1).

Table 1: Mean age at initiation of the particular drugs and the frequencies of their use.

Fentanyl ¹ Amphetamine Heroin Homemade opiates²

1 Fentanyl / fentanyl analogs: China White or Persian White ³⁶

2 Home made opiates: home made poppy liquid Adapted from Uusküla et al. 2006

Injecting drug users in the sample who mainly injected China White/heroin were significantly more likely to be HIV-positive than injectors of other illicit substances (e.g. amphetamine, homemade opiates). A key factor that potentially contributes to the higher prevalence of HIV amongst Fentanyl (and heroin users) is needle sharing, a risk behaviour that is significantly more likely to be reported by Fentanyl users (29.5%) than users of home made opiates (17.4%) or amphetamines (19%). The same study showed that 29% of respondents had practised the sharing of needles and syringes and other injecting supplies in the previous four weeks.

It was also evident that IDUs involved in the research had little contact with harm reduction initiatives, for example, 50% had never accessed a syringe from an outreach worker. Also, 71% of the respondents had been arrested by the police, often for possessing or using injecting equipment and drugs or being

36 The illegal drugs known as China and Persian White (in Estonian: Valge hiinlane, Valge pärslanee) appeared in the Estonian illegal drug market in 2001. According to the National Institute on Drug Abuse (NIDA), US, fentanyl and fentanyl analogs such as Actiq, Duragesic, Sublimaze (commercial names) known by street names as Apache, China girl, China white, Dance fever, Friend, Good fella, Jackpot, Murder, 8, TNT, Tango and Cash are administrated by injection, smoked or snorted (NIDA 2004). Fentanyl is 50 times more potent than heroin and can rapidly stop respiration (NIDA 2005).

accused of selling drugs. Many had subsequently been in prison (64%) and almost two thirds reported injecting drugs during their time in prison, most had shared needles. There was an extremely high prevalence of HIV, 62.1% of the whole sample, and as demonstrated in previous studies (Kang 2005; Wood 2005), being in prison was seen as an extremely high risk factor. In addition a high proportion of the IDUs surveyed did not have health insurance (55%) and the majority came from the Russian community (Uusküla et al. 2006).

Given the high prevalence of HIV among IDUs in this study and the common practice of incarcerating them it is very likely that the problem of HIV transmission in jails and prisons is increasing. Programmes to reduce HIV transmission in jails and prisons, including drug-abuse treatment of inmates, syringes exchange, and programmes to reduce the likelihood of incarceration of IDUs, are urgently needed (Uusküla et al. 2006).

3.3.13 Alcohol use

Estonia has one of the highest alcohol consumption levels, with 86% of the population (aged 16–75 years) consuming alcoholic beverages (Estonian Institute of Economic Research 2003). There is wider use among men, young people and those with lower education, and use is greatest in the North East and in small towns. Generally, wine and beer is most consumed, with stronger alcoholic drinks being consumed by older people. Due to its alcohol consumption, Estonia is considered among the most unhealthy states (World Health Report 2002).

There is rising concern regarding alcohol consumption among young people and the link with problematic use during adulthood. Sixty per cent of those aged 10–13 years, have tried alcohol. Fifty-five per cent of 14–15 year olds reported they having been drunk at least once and 52% are regular alcohol drinkers, which rises to 69% for those aged 16–18. Along with concerns about consumption, the general population of Estonia is considered to be at high risk of other problems associated with problematic alcohol use, such as alcohol-related psychosis, injuries, suicide and traffic accidents as a result of driving while intoxicated (National Institute for Health Development 2004).

3.3.14 National drug strategy

Responsibility for the overall administration of the Alcoholism and Drug Prevention Programme 1997–2007 rests with the Ministry of Social Affairs, and the National Institute for Health Development the main institution responsible for the implementation of the programme. In 2004 the Ministry of Justice of Estonia initiated a discussion on alternatives to prison for drug users, as the current provisions in the Penal Code, passed in June 2001, were not being put into practice, due to very limited access to drug treatment in the

community. Therefore, improving the quality and accessibility of services for drug users in the community were given priority in the Alcoholism and Drug Prevention Programme in 2004. Consequently, in 2005, the National Strategy on the Prevention of Drug Dependency 2004–2012 took effect, which aimed to deal with:

• prevention of drug use (managed by the Ministry of Social Affairs, the National Institute for Health Development and the Ministry of

Education and Science);

• treatment/rehabilitation and harm reduction (managed by the Ministry of Social Affairs and the National Institute for Health Development);

• supply reduction (managed by the Ministry of Internal Affairs);

• drugs in prison (managed by the Ministry of Justice);

• monitoring and evaluation of drug situation (managed by the Estonian Drug Monitoring Centre, governed by the National Institute for Health Development). (EMCDDA 2005)

3.3.15 The healthcare system

The Estonian health care system was subjected to reforms during the early 1980s resulting in a shift away from a centralised and state-controlled care delivery system to a decentralised system, including private provision based on health insurance. The main reasons for reform were that:

• there was no relationship between health care expenditure and the national economy;

• the health care system had too much hospital capacity and too many specialist-doctors for the needs of the Estonian population;

• alongside over-capacity in the secondary and tertiary care sectors there was a disproportionately weak and underdeveloped primary health care system (MacDonald 2004).

Another key date was 1995, when the public health system was reorganised (Public Health Law 1995) to establish the appropriate structures, role and finances for the provision of public health.