In the European context, new psychoactive substance (NPS) use was a concern among marginalised, vulnerable or socially disadvantaged groups, including homeless people, unemployed people, prison populations and people with mental health problems.[1–3] In the past, synthetic cannabinoid use in high risk drug-using populations has been reported in two-thirds of the countries reporting to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), while problematic use of synthetic cathinones has been reported in half of the countries.[1] However, more recently, synthetic cannabinoids appeared more frequently as replacement or adulterants sprayed on herbal cannabis or other THC products.[4]

In contrast, NPS use in Hungary is still a great concern, posing substantial burden to the most marginalised and vulnerable populations both in cities and in villages.[5–11] NPS use first appeared in Hungary in 2010, and rapidly transformed the drug market. Once NPS became available in the drug market, people who inject drugs (PWID) transitioned to NPS injecting from traditional substances.[12,13] The percentage of heroin users started to drop and gradually, amphetamines were replaced by NPS as well.[12,14] Transitioning to NPS increased the health risks of PWIDs, as NPS use have been associated with a higher number of daily injecting episodes. Meanwhile, reduced government funds and political attacks decreased the availability of harm reduction services in the country.[15] This created an environment where the most marginalised and vulnerable subpopulation of people who use drugs (PWUD) faced significant risks without any prospect of meaningful support from the social or health services.

In the past decade, NPS use has become a widespread phenomenon among marginalised communities in Hungary.[5–7,11] Furthermore, traditionally, substance use was considered an urban phenomenon. Since 2010, when NPS became widely available in the Hungarian drug market, a growing number of reports in grey literature and anecdotal information among professionals have become available on NPS use among previously unaffected groups: people living in rural and socioeconomically deprived communities. The situation is unfavourable to PWUD in general, but even more so for PWUD living in rural areas. People have limited access to the labour market, most of the services of the social and health welfare system are not available locally, and the public transport system is inadequate. Substance use-related services are situated in the major cities and are practically inaccessible for those who live in villages. The distribution of the healthcare system is also unequal, for example, general practitioners are typically available for only a few hours a week in small villages. The coverage of the social welfare system shows a similar pattern; basic services are usually available locally, but services capable of addressing more complex issues are available only in the cities.

Research conducted to explore NPS use in marginalised communities brought to attention a few characteristics of the phenomenon. First of all, it is important to add that NSP use is not the biggest substance use problem in those communities. Tobacco, alcohol, tranquilizers (benzodiazepines) without prescription or alcohol and tranquilizers together are far more widely used in these communities.[5,9] A study exploring substance use in segregated communities in villages found that three quarters of the respondents drank alcohol in the last month, half of them used tranquilizers, while one fifth used synthetic cannabinoids and less than one sixth of the respondents used synthetic cathinones.[9] When we consider NPS use, reports showed that NPS use is prevalent in every region of the country. Though prevalence rates or the most frequently used substances could differ from community to community, NPS use can be found in most cities and villages. However, the injection of NPS seems to be more frequent in cities compared to villages.

According to the researchers, people living in marginalised communities in villages can access NPS easily.[5,9] Sometimes, they have an easier access to NPS than to alcohol or tranquilizers. NPS users mostly buy the drugs from friends or well-known dealers, typically locally, but NPS users living in villages sometimes have to travel to the closest city. Traditional substances, like cannabis or amphetamines are the least accessible substances in these communities, showing how deeply NPS could penetrate communities where illegal substances were not common before. Price can be a factor too: one cigarette with synthetic cannabinoid could cost the same as a can of beer, while the level of intoxication one can achieve is greater with a synthetic cannabinoid cigarette, which can knock you out completely. Interviews conducted with NPS users showed that using alone is the most common form. NPS use most frequently happens alone; users hide in abandoned houses and buildings.[7] People also use it together in small groups, hidden and away from the public eye. Substance use in public places is only occasional and, although it occurs in larger groups and in public settings, it was found to be the least common. The reason behind this is the strong stigmatisation of substance use in those communities, with the strongest stigma linked to use through injection.

Asking for help and accessing drug related services could be a serious problem as the coverage of such services is inadequate in the country. NPS users living in villages are in the worst situation, as specialised drug related services are practically unavailable there. Asking for help is hard in itself, and finding a service in a foreign city is an even more complicated task. The cost of transportation is a huge barrier, and they usually can’t afford to travel regularly to another city. Research data on access to services showed a similar picture, where the main contact with the social welfare and health care system for NPS users in villages was the general practitioner.[6] Although we are talking about one of the most vulnerable populations, the majority did not report meeting with a social worker over the past year. Marginalised people who live in cities and use NPS are in a slightly brighter position. They are usually in contact with two or three services, one of them being a shelter or similar service for people experiencing homelessness.[10] The other is usually a substance-use related service – most commonly a harm reduction service or other low threshold service for people who use drugs.

It is important to highlight that respondents frequently reported distrust in the social care system (and in all forms of service in general).[6] And this distrust is not unfounded. The stigmatisation of people who use drugs in Hungarian society is very high, which, together with the criminalisation of substance use makes risky to openly admit substance use, even while seeking help. When asked about whom they can trust if they need advice or help regarding their substance use habits, interviewed marginalised people who use NPS usually chose their family in the first place.[6] The majority of the respondents said that they can fully trust their family with substance use related issues. General practitioners were the second after family, but only half of the respondents felt that they can trust their general practitioner. Friends who do not use any substances and employees of the local social service were among the least trusted people.

When we consider the motives in these communities to use NPSs, research on the subject consistently highlights the role of structural causes behind substance use. Though individual frustrations, lack of problem-solving strategies, lack of coping with tragedies and traumas can all play a role, the main causes of drug use in these marginalised communities (cities and villages alike) are clearly social exclusion, poverty, deprivation and hopelessness, the lack of prospect for a job, appropriate housing and so on. Substance use is part of a coping strategy and a means of escaping from reality, from psychological problems, poverty and misery and of coping with the stress of fighting for survival.[7]

NPS use among marginalised people is a very complex problem, involving both legal and illegal substances, and characterised by a combination of stigma and disadvantages due to their substance use and their social status. Those who live in rural communities live in socioeconomically deprived areas where they do not have proper access to the health and social welfare system, do not have access to substance use-related services, but can access NPS and tranquilisers. Outside their communities, marginalised PWUD would face stigma and social exclusion because of their substance use, often experiencing inappropriate or even inhumane treatment at social or health services. When designing possible interventions to address this issue, it is crucial to take into account the perspective of people who are confronted on a daily basis with the difficulties and hopelessness of their lives, in which substance use can be functional as a rational strategy that could help them survive in everyday situations that are shaped by an uncertain future. Using NPS in a socioeconomically deprived community is a position where physical, economic, social and policy disadvantages are intertwined, and interventions addressing addiction and substance use alone might not be effective. Addressing inadequate coverage of health and social services, introducing mobile harm reduction services, outreach programs and peer-based interventions could improve the situation. However, without social policy and labour market instruments that can improve the opportunities of people living in the segregated communities, these interventions alone will not be sufficient.

References

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