Dawid Krawczyk: It’s not always easy to talk with you.
Agata Kwiatkowska: Why is that?
You use a lot of drug policy lingo. For instance, I read your latest report on the needs and challenges that “injection drug users” face. So, who are they exactly?
Magdalena Bartnik: They are people who take psychoactive substances via injection.
You mean they take a syringe and shoot the drug into their veins, right?
M.B.: It doesn’t have to be intravenous use, it could be intramuscular as well. Guys who inject steroids at the gym are injection drug users, too, even though most people don’t recognize them as such.
A.K.: Or some successful office workers, who live so-called ‘regular lives’, snort cocaine on a regular basis, and sometimes they inject it, but they also don’t pass as injection drug users.
So, you’re not actually talking about anything new. Wikipedia says that syringes were already widely used in the 19th century. Has no one researched the issue since that time?
M.B.: Of course research has been done, and is still being done. Usually these are qualitative research papers. Injection drug users are counted regularly in an attempt to give some kind of clarity to the image of the current situation. They are asked how much they take, for how long they’ve done it, and if they’ve suffered from infection. But very rarely does the information come directly from the users – they are not approached with questions regarding their needs and challenges.
A.K.: That’s all true, but let me provide some context for that. Why have we conducted this research today, in 2016? Since the late 90s, we’ve heard in Poland that there are fewer and fewer injection drug users, which is a perfect argument for deepening cuts to shelters, emergency hostels, and needle exchange programs. Year after year there are fewer of these facilities. At a meeting with the Ministry of health we were told that injecting drugs is a thing of the past, an issue of the drug users from the 90s – hippies, musicians, bohemians.
The fact that users with dependency on injecting psychoactive substances don’t visit healthcare agencies doesn’t mean that they disappeared.
There is no reason to act self-satisfied. Our research shows that the culture of drug-taking is constantly evolving, and anti-addiction campaigns can’t keep up the pace.
M.B.: It was always like that, only part of the whole population of injection drug users is visible – the part above ground. In the 90s, you could spot them on the streets. When the first drug substitution treatments began, it ‘cleaned’ the streets a bit, because people started visiting these places. Then there was the bill in 2000 criminalizing users and pushing them underground. And so some of them are literally underground right now, and some live in high buildings.
You mean skyscrapers, or blocks of flats?
Both, actually. It’s a more diverse group than you might think. The injection user is not only – as the stereotype would suggest – an opiate user living on the margins of the society.
If injection drug users are forced to live in hiding, how did you reach them? You wrote on Gumtree that two girls from Warsaw are looking for guys who inject drugs?
M.B.: We didn’t have to, fortunately. It was relatively easy in Warsaw, because I know the scene here. There were four other cities, though: Gdańsk, Cracow, Lublin and Poznań. But it wasn’t especially hard there. I think if you honestly want to speak with someone about their issues, it’s easier.
A.K.: We arrived in front of the clinic, where addiction treatments and harm reduction services are located and started to chat casually with the guys there. During our chats we were introducing the topic of our research, and our goals and motivations. When we started asking about their needs, it transformed into a sincere conversation about living with addiction. It wasn’t as easy when we tried to cooperate with substitution therapy centres; they literally threw us out of the clinic in Cracow. So, we stood beside the fence nearby, and spoke with those leaving the place. No one was really surprised that we were hanging around outside the building. Can you believe that they can’tstay on the facility’s premises? I couldn’t believe that, considering that rooms for the patients to rest is a standard thing in the West.
M.B.: Honestly speaking, our research was successful mainly due to the enormous involvement and determination of the users we met. Within moments they would take out their phones and start calling their friends, who would come from the other side of the city just to take part in the focus group.
And how exactly were you introduced in these calls?
A.K.: Yeah, right, I remember those conversations well. “Hey man, I’m here right now with these two girls from Warsaw, and they want to talk about our needs, you feel that?”. “Seriously? About needs? Fuck, what? How is that? What for?”. They were genuinely in shock that someone wanted to speak with them about their actual needs. The questions they hear most of the time range from “When was your last hit?”, to “Are you infected?” and “Have you had your HIV test?” They couldn’t believe that we really wanted to talk about their lives. And that’s basically how we gathered up our focus groups.
M.B.: It’s probably important to mention that participants were offered a 50 zloty gift card from Empik (a network of bookstores). But the question about their needs really threw them. I remember one guy said that if we honestly wanted to talk about his needs, he had a roaring need to grab a beer, and asked us for 3 zloty.
A.K.: We gave it to him, but only after completing the survey, of course.
Besides a beer, what are their needs?
When it comes to people that are not in substitution therapy, their entire life is subordinate to pursuing a fix.
M.B.: The need for the substance becomes their first priority. That’s is basically what addiction is all about, isn’t it?
A.K.: We met young women who shoplift in order to get money for their fix. They don’t resemble the stereotype of a drug user at all – attractive, well-groomed ladies. But the make-up and the outfit is a way to score the substance. They need to look like that, or they couldn’t get into H&M or Zara to steal. It’s not uncommon that they live double lives, hiding their addiction from their families. One of them told us how she was caught by her husband. Her three year old daughter peeped in on her when she was smoking heroin, and later, as kids do, mimicked her mother. Unfortunately, she did it in front of her dad and granny.
M.B.: The life of such a person revolves around one thing, how to take the edge off. But it doesn’t get them high, or even give a kick any more. It’s just a way to feel normal again, and not tremble in the morning. And you always have to think about the next dose before you fall asleep, always. That is, in short, the reason we need methadone (a medicine used in substitution therapy), or another substitute for those dependent on opiates. It lasts longer and eases the cravings. You don’t have to hustle so much to get a fix – and hustling, after some time, becomes extremely hard, full-time work.
You claim that one can’t get rid of this need for the substance once and for all?
A.K.: I’m sorry to say it, but no, they can’t. You can learn how to live with it, though.
M.B.: Most users will have this need, probably forever, and it has to be satisfied.
A.K.: Because if a person is constantly thinking about getting a fix, they aren’t able to take care of their other needs. It’s as simple as that.
So, it’s not true that starting a new hobby, falling in love, coming to terms with yourself, family, and your loved ones will wash away the need for the substance?
M.B.: There are people following the scenario you’ve just described – emotions that accompany those kinds of life events leads to a temporary pause in taking drugs. But does it end addiction permanently? It’s extremely rare. If you just focus on the cravings, and don’t work on other areas, it’s almost impossible to change your way of life.
And when the drug cravings are eased, what then?
A.K.: Then you can think about a place to stay, food, safety, and work. Work is extremely important, and it popped up a lot during our interviews. When you start a new job it means that someone trusts you. And there’s gratification, payment for the work – meaning that you’ve gained approval, something that people living with chronic addiction don’t experience a lot. Work is crucial for successful treatment, it has a significant role in therapy. Unfortunately, criminalization of drugs, sentences for crimes committed to support the addiction, life on probation, bailiffs, debts – that all combined makes legal work almost impossible.
M.B.: The hard part was questions about higher needs. Some of the guys we interviewed reacted aggressively to the very idea of talking about pleasure coming from reading books or going on holidays. For most of them it was an abstract thing, and that caused frustration. We heard that they’d hit rock bottom, that they had lost all hope. During one of the focus groups sessions these kinds of questions even provoked a brawl.
What still remains unanswered is if satisfying those other needs leads at some point to a decrease in the need for the drug. Not a total disappearance, but at least a decrease.
We don’t know yet, but with this report we want to start a discussion about how we can treat addiction differently. The compulsion to fulfil the need for the substance, this basic need, should be perceived in the broader context of the assets that a person has at their disposal.
One way to safely satisfy this basic need is substitution therapy. Instead of shooting up, one can come to the clinic, drink a bottle of methadone, and have the cravings eased off for a time. What pushes users to start such therapy?
A.K.: They get tired.
M.B.: Exhausted by all the drudgery that comes with pursuing the next fix.
A.K.: Mostly, there are health reasons. I remember young guys, who told us that their veins were so ruined that they simply can’t take it anymore. They knew they needed a break.
M.B.: Starting therapy is often the moment, when you realize the risk that comes with drug injection, or unprotected sex. General health risks.
What kind of risks are we talking about?
HIV, Hepatitis C, abscesses. An injection is a serious medical procedure, which should be undertaken in a sterile environment. Most injection drug users shootup hiding somewhere on a staircase or in the bushes. Another risk is an overdose. Even if you don’t use alone, but with your mates, there is a huge chance they won’t call the ambulance, out of fear of the consequences.
A.K.: Risk doesn’t affect only users, but the whole of society. Let’s say that someone uses a needle, doesn’t sterilize it, and throws it away on the street – that’s another risk. We are talking about public health for a reason – harm reduction aims to protect all members of the society, not only users. It would be great if those who don’t use understood that a good needle exchange in their neighbourhood benefits their health and safety as well.
Does this mean that giving out methadone solves all drug-related issues? Users’ lives straighten out, the streets are clean of dirty needles, and everybody lives happily ever after?
M.B.: Nowadays, these substitution programs function as if they believe that therapy works exactly like you just described. Well, it doesn’t. You can’t just catch an opiate-user, tell him to sit down and drink methadone, and then say “See ya later, mate”. It’s not enough. There are other needs that have to be taken care of. I think that our research says a lot about how human beings function in general, and proves the biopsychosocial theory of addiction.
That’s what I was talking about at the beginning…
In short, it says that in order to influence the negative behaviour of users (as well as understanding their addiction and responding with meaningful help) one has to address three areas – psychological, biological, and social – simultaneously. Addiction doesn’t have one source, it is a result of many factors. Dealing with it should take all of them into consideration. The same applies to decreasing the risk attached to the manner of drug-taking. If the most basic needs are satisfied, less risky behaviours are undertaken.
A.K.: Giving out methadone syrup won’t solve the problem. In Cracow, where they wouldn’t let us in, we heard stories: back in the day, there had been chairs in the waiting room, but now they’ve thrown them out and deactivated the power sockets. You know, to prevent their patients from charging phones. It’s kind of grotesque. The system is designed in a way that users are coming, drinking syrup, and going to hell.
You write in your report that it’s not uncommon that people in substitution therapy ‘supplement’ it, meaning that they inject drugs anyway.
M.B.: Because the medicine alone is not enough. It only eases the cravings for drugs. But psychological needs are still unsatisfied. Many people told us that they feel high while they inject, even when it’s just methadone. It’s all about the feeling that comes with inserting needle into the veins.
Injecting methadone? Isn’t it a syrup to drink?
It is, but you can inject it as well. Generally, most users shift to injection, simply because it’s economical – while injecting you don’t lose even a milligram of your stuff. Then they develop an attachment to the injection, ritualize it. And many people get prescribed doses that are too small, that’s why they’re buying methadone on the black market, or supplement their therapy with other drugs.
The head of the National Bureau for Drug Prevention in Poland said during the release of your report that the dosage has to be small, because it’s possible to overdose on methadone.
A.K.: That’s right, you can overdose. But at the very same meeting Dr Janusz Sierosławski of the Institute of Psychiatry and Neurology in Warsaw said that this argument is invalid. First of all, if someone needs more methadone, they will buy it on the streets and overdose on it anyway. And secondly, if a person wasn’t on the program, they would probably overdose on heroin, so what are we actually talking about? Wouldn’t it be better if users could take the drug in safe conditions, not somewhere on a dirty staircase?
M.B.: Now we have substitutes provided via therapy and the black market that regulate what doesn’t work in the substitution model. When you get a week’s supply, you can resell some of it, because reality means you have to have money to spend on other things. When your dose is too small you try to find a fix on the streets.
A.K.: Additionally, many people don’t want to join the substitution programs and be on this ‘methadone leash’, to be subjected to constant control. They don’t want to take part in an environment that reminds them of the life they’re trying to escape. It would be reasonable to follow the majority of the European countries and transfer methadone from the clinics to the pharmacies. Of course there are people who need the substitution programs, but European statistics shows that the majority prefer to collect their medicine from a drug store. Moving a substitute to the pharmacies could help us get a realistic count of opiate users in Poland.
You did your research, you can back your statements with scientific data. But I can’t help thinking that tomorrow we won’t wake up in some new reality where methadone finds its way to pharmacies, and people suffering from addiction are offered council houses, jobs and therapy.
M.B.: You know, topics like HIV, Hepatitis C, and risky behaviours don’t even cross the minds of the vast majority of the general public. That’s mainly due to the stigmatization and exclusion of drug users, there is this pervading thought that life has to take its toll on them, and the weak individuals have to pass away.
A.K.: We live in a reality where people just don’t get how much they need harm reduction – meaning, professional services designed to minimize the risks they face. And it doesn’t concern only the users. It has been proven that in every city with professional harm reduction services there is a decrease in crime. When we went to the district council meeting in Warsaw, we heard that there is shortage of toilet paper in kindergartens, and how dare we demand money for some whim like needles for ‘junkies’. It’s a serious problem.
OK, I get it. But how does your report solve this?
The report’s goal is to initiate a discussion about what is being financed by the Ministry of Health and the Polish Government when it comes to drug policy. At last, we have to stop believing that we can send opiate users to long-term drug-free therapy in closed facilities, and that thanks to hard labour and meditation they will stop taking drugs. We have to admit the fact that there are people who will never stop using drugs, and they need to be taken care of too. They need constant care, professional health services, and much less rigorous substitution therapy. Another issue is the attitude of clerks working in drug policy programs: they are often embarrassed that they work in this field. They stigmatize themselves and their clients. But what’s worse is that when it comes out that they themselves are addicted, they’re being automatically laid off. We have to start talking about this openly. If someone outside the drug policy circles gets their hands on this report, they might realize that taking drugs is not a mortal sin, but a much more complicated issue.
M.B.: This system we have to deal with now has to be fundamentally rebuilt. Starting with finances. Today, money goes mainly to prevention, ineffective by the way, and only scraps are spent on harm reduction. It’s not true that there is no money, it’s just poorly managed. The proportions are upside down. People take various drugs, and most of them will never suffer any of the serious consequences of that – that is the truth that has to be finally acknowledged. But the part of the population that develops an addiction should have access to professional healthcare – even if they’re still using. Abstinence is not an achievable goal for most people. We have to come to terms with the fact that a significant number of drug users will take drugs, and the only thing that can be done is to minimize the risk is to answer their needs.
But the most important conclusion that should be drawn from this research is that injection drug users are citizens of this country, and their rights must be respected.
If the state doesn’t support their basic needs, doesn’t care about their health, it simply isn’t fulfilling its duties. If there is no real harm reduction service in the neighbourhood, and pharmacies don’t sell clean needles and syringes, it’s as if we’re condemning drug users to an enormous risk. And by the way, it’s 2016. We could have done something by now. It doesn’t have to be started from scratch, there are solutions that have proven to be effective in other countries.
Magdalena Bartnik – cofounder and head of the Fundacja Redukcji Szkód (Harm Reduction Foundation). She studied Judaic Studies at the Jagiellonian University in Cracow and Culture Studies at University College London. She specializes in addiction therapy, and took part in a number of international training meetings in public health, human rights, and drug policy. She is an Open Society Foundations fellow at the seminar on Human Rights and Drug Policy at the Central European University in Budapest, and alumnus of the seminar on Evidence-Based Drug Policy at the Institute of Philosophy and Sociology of the Polish Academy of Sciences.
Agata Kwiatkowska – trained as a political scientist and public health specialist, and fights for various social causes as an activist. She runs the advocacy program in Fundacja Edukacji Społecznej (Social Education Foundation) in Warsaw.