Skaidre 1

1
Combating Drugs a World Challenge Kova su
narkotikais pasaulinis iukis June 1-2,
2006 VILNIUS
2
(No Transcript)
3
Subutex in Finland
4
BUPRENORPHINE, AN ABUSED OPIOID

• Prof. Erkki Vuori
• 02.06.2006

Department of Forensic Medicine, University of
Helsinki
5
OPIOIDS ARE IMPORTANT DRUGS IN MEDICINE AND IN
FORENSIC MEDICINE

• Opioids are needed as centrally active
  analgesics, especially in the treatment of severe
  pain
• Opioids are also badly abused
• Dealing in abused opioids is linked with
  organized crime
• The usual way to abuse opioids is by injecting,
  which involves health risks
• All opioids share a common mechanism of action
  via µ-receptors µ-1 for analgesia, µ-2 for
  respiratory depression
• All opioids can cause sudden death
• Abusers develop tolerance

6
OPIOIDS AND µ-RECEPTORS
7
ADVERSE EFFECTS OF OPIOIDS

• Pinpoint pupils (miosis)
• Confusion, dizziness
• Respiratory difficulty (failure to respond to
  increased CO2)
• Cardiovascular changes hypotension
• Gastrointestinal symptoms (nausea, constipation)
• Hypothermia
• Bronchial constriction
• Convulsions
• Coma

8
OPIOIDS

• Agonists
• natural morphine, codeine
• semi-synthetic heroine, oxycodone, ethylmorphine
  
• synthetic methadone, proproxyphene, fentanyl,
  tramadol
• Antagonists
• naloxone, nalophine, naltrexone
• Partial agonists/antagonists
• buprenorphine, pentazocine

9
BUPRENORPHINE 1

• Is a semi-synthetic opioid derived from thebaine
• First synthesized in the USA in 1973
• Buprenorphine (Temgesic, Subutex, Suboxone) is
• as an analgesic 25-40 times more potent than
  morphine
• as an antagonist equivalent to naltrexone
• Has a ceiling effect higher doses do not
  produce greater effects
• Has low oral bioavailability, but can be taken
  sublingually
• Has an active metabolite, norbuprenorphine

10
BUPRENORPHINE 2

• For treatment of pain the usual dose is 0.3-0.6
  mg parenterally or 0.2-0.4 mg sublingually every
  6-8 hours
• For maintenance therapy high strength tablets are
  available (2 and 8 mg), dose up to 16 24 mg
• The duration of action is long, up to 72 h
• Withdrawal symptoms appear slowly
• High-dose buprenorphine treatment for heroine
  addicts was first approved in France in 1996
• And later approved in Australia, Germany, USA,
  Finland
• BUT buprenorphine is also abused

11
BUPRENORPHINE 3

• Abusers take it sublingually, intravenously or by
  snorting. The typical intravenous dose is about
  1 mg 2-3 times a day, sublingual dose up to 24 mg
  day
• Sublingual bioavailability is 50 and oral 16
• Therapeutic blood level is up to 10 µg/l
• Drug levels in fatalities are 1.1-29 µg/l,
  average 8.4 µg/l!
• There is no safe therapeutic concentration for
  opioids. (Drummer 2001)
• Typical fatal combination
• Buprenorphine
• CNS-acting agents
• benzodiazepine derivatives
• antipsychotics
• Alcohol

12
WHY IS ABUSE OF BUPRENORPHINE (SUBUTEX) COMMON IN
FINLAND?

• Good reputation Subutex is manufactured by a
  pharmaceutical company
• It is a simple tablet, not a hazy powder
• The quality is high and quantity is consistent,
  tablets are easy to divide and dose
• It can be used via several routes sublingually,
  intravenously or by snorting
• Used alone, buprenorphine is not particularly
  toxic
• It has a legal status it is a therapeutic agent
• The abuser can always claim that he or she is
  using it for treatment

13
HEROIN AND BUPRENORPHINE IN POST MORTEM FORENSIC
TOXICOLOGY IN FINLAND
14
ABUSED BUPRENORPHINE, FINDINGS AND DEATHS IN
2000-2004
15
BUPRENORPHINE 4

• In Finland the legal use is strictly controlled
  and is foolproof
• Illegal buprenorphine first came from France, but
  now comes mostly from the Baltic countries
• We have a drug tourism problem
• 1-day trips
• local general practitioner gives the prescription
  
• possibility of contacts with several doctors
• extra drugs are sold in Finland
• trafficking trips are organized
• The result buprenorphine is at present the main
  injected opioid in Finland and in many cases the
  first opiate used by young abusers.

16
(No Transcript)
17
Needle exchange programs
18
What science tells us about needle exchange
programs

• Kerstin Käll, MD, PhD
• University of Linköping, Sweden
• Klas Rönnbäck, Ulrich Hermansson, Sten Rönnberg

19
HIV and Injecting Drug Use (IDU)

• Two parallel world wide epidemics
• an epidemic of IDU, starting in the developed
  world after WW II, now spreading in producing
  countries and along transit lines
• an epidemic of HIV among IDUs, also starting in
  the developed world in late 1970s, now hitting
  hardest in the developing countries and former
  Soviet Union

20
WHO strategy to fight HIV among IDUs

• Preventing drug abuse
• Facilitating entry into drug treatment
• Establishing effective outreach to engage IDUs in
  HIV/AIDS prevention strategies that protect them
  and their partners and families from exposure to
  HIV and encourage the uptake of drug dependence
  treatment and health care.

21
WHO strategy to fight HIV among IDUs

• Furthermore it is stated that the national
  policies should be based local circumstances and
• Policies employed should be evidence based

22
WHO/UNAIDS guidelines

• E.g. Advocacy guide HIV/AIDS prevention among
  injecting drug users
• Unfortunately, certain effective but
  controversial elements are neglected in many
  countries. Important service elements that tend
  to be neglected include drug dependence
  treatment, outreach activities and needle and
  syringe programmes.
• In this document HIV-testing and counselling is
  not even mentioned in any project

23
WHO/UNAIDS guidelines

• In fact, NEP and substitution treatment are the
  main elements suggested to combat HIV among IDUs
  in all WHO/UNAIDS documents, suggesting that
  these are indeed evidence based methods to do
  this.
• All successful examples mentioned include either
  or both but rarely anything else.
• Is it true that NEP is an evidence based method
  to prevent HIV among IDUs?

24
The Swedish example

• In 1985 HIV prevalence among iv heroin users was
  over 50 in Stockholm
• The debate on how to meet the epidemic of HIV
  among IDUs resulted in Continued fight against
  drugs HIV testing, counselling and education to
  fight HIV among drug users
• The fight against drugs should have priority as a
  means to minimise the vulnerable population

25
The Swedish example, cont.

• If HIV-prevention policy comes in conflict with
  anti-drug policy it should not be implemented.
• Needle-exchange was seen as coming into conflict
  with the policy to discourage young people from
  trying drugs and particularly injecting drugs

26
The Swedish example, cont.

• Thus it was not implemented on a national basis
  and particularly not in Stockholm, where the
  majority of the HIV infected IDUs lived.
• This was in conflict with WHO recommendations and
  we have been much criticised for this. In Sweden
  it is still under debate and this spring a law
  was passed that opens up for NEP.

27
The Swedish example, cont.

• Many other HIV-prevention policies were however
  employed
• Free HIV testing and counselling in prison,
  hospitals and treatment units
• Increased possibilities for methadone maintenance
  treatment (high threshold) with priority for HIV
  positive heroin users
• Special hospital units for drug users with
  infectious diseases
• Increased possibilities for drug treatment

28
The Remand Prison Study

• In 1987 a study of HIV and HIV risk behaviour of
  IDUs was initiated in Stockholm. It closed in
  1998 and then reopened in March 2002.
• An independent team performs a structured
  interview of risk behaviour and takes an HIV test
  of IDUs entering Remand Prison in Stockholm

29
Yearly incidence () of HIV among IDUs at Remand
Prisons in Stockholm
30
IDUs participating 2002-2005. N1246
Amf.41/790 (5,2) Heroin 26/456 (5,7) All 5,4
31
The Remand Prison Study

• The new HIV cases in recent years are mainly
  older, heavy, male IDUs, often homeless with
  multiple problems
• No indication of spread among young new IDUs.
  Exception 2005 two young IDUs
• The willingness to test is high as well as the
  interest in information about HIV and hepatitis

32
The Remand Prison Study, conclusion

• Paradox of continued high risk behaviour but
  decreased HIV spread
• The most important factor in the reduction of HIV
  incidence seems to have been the testing and
  counselling among IDUs in combination with
• The openness of IDUs among themselves about HIV
  status. They avoid sharing with HIV positive
  users.

33
The Swedish experience

• Since the strategy had been relatively successful
  there was no good reason to change it
• Since the discussion on needle exchange had again
  come up we decided to look at the scientific data
  collected on needle exchange programmes (NEP)

34
A NEP a literature review

• A total of 143 articles were found by data base
  searching and reference lists
• 2 criteria some effect measure of NEP and some
  sort of control/comparison group
• 69 articles met these criteria and were included

35
NEP - Randomised Controlled Studies (RCS)

• Only two randomised controlled studies were
  found, both from Anchorage, Alaska (2002 and
  2003)
• The first study looked at needle sharing and
  cleaning the other at injection frequency

36
NEP - RCS

• No significant difference between study and
  control groups were detected, but both groups in
  each study improved their habits
• The authors concluded that the initial HIV
  information given to all was the effective
  measure

37
NEP - non-randomised studies

• The majority of the reviewed studies used self
  reported change of behaviour - e.g. needle
  sharing or treatment seeking as outcome
  variables without any measure of actual effect on
  HIV incidence or prevalence. Contradictory and
  confused picture.
• Focus on studies of HIV incidence and prevalence
  - 13 studies

38
(No Transcript)
39
(No Transcript)
40
Summary of table

• Incidence 1 pos, 1 negative, 7 inconclusive
• Prevalence 4 negative (baseline measure) 2
  positive (change of prevalence)

41
(No Transcript)
42
Incidence prevalence studies

• The Vancouver studies
• NEP established in 1988 when prevalence was 1-2
• Rapid phase of epidemic started 1994
• None of the studies showed any protective effect
  of NEP

43
Incidence prevalence studies

• The Montreal study 1988 to 1995 1599 IDUs
  enrolled
• Baseline prevalence NEP-users 16 non-users
  5.8 (sign. diff.)
• 974 HIV-neg IDUs followed
• Incidence 7.9 for NEP-users 3.1 for non-users
  (sign. diff.)

44
Incidence prevalence studies

• New York 1996 meta-analytic study 1988-95
• High prevalence, around 50
• Past peak of epidemic
• Significantly higher incidence among non-NEP
  users compared to NEP users
• Sex, age and frequency of injection controlled
  for but not homelessness

45
Incidence prevalence studies

• Scandinavian study on population and register
  data 1991-96 using back calculation
• Similar epidemics in Denmark, Norway and Sweden
  (mainly in capitals) with peak in mid 1980s
• NEP in Denmark and Norway, not in Sweden

46
Incidence prevalence studies

• HIV testing counselling promoted in Norway and
  Sweden, but not in Denmark
• Lower incidence in Norway Sweden compared to
  Denmark indicating that HIV testing and
  counselling may be more important than NEP in
  preventing HIV

47
Incidence prevalence studies

• Recurring predictive factors for HIV
  seroconversion
• Frequent injection
• Cocaine injection
• Homelessness/unstable housing
• NEP most often not significant - exception one
  negative and one positive

48
Incidence prevalence studies

• Two studies comparing cities with and without NEP
• using measurements of HIV seroprevalence from at
  least two calendar years
• Hurley et al 81 cities and MacDonald et al 99
  cities
• The average change in seroprevalence is lower in
  NEP cities than in non NEP cities in both studies.

49
(No Transcript)
50
Incidence prevalence studies

• Methodological problems
• The stage of the epidemic in the included cities
  not stated
• Cities without an epidemic may not have been
  included unless they had NEP
• NEP often introduced after rapid phase
• Measurements often done during the rapid phase

51
Incidence prevalence studies

• Conclusion
• Of 13 studies on the effectiveness of NEP in
  preventing the spread of HIV among IDUs
• one showed positive result
• two positive but with questionable methodology
• 10 either negative or inconclusive

52
Comments on Wodak et al report

• Much the same studies - opposite conclusion
• Incidence and prevalence table 3a-c
• 6-5 (positive vs neg/inconclusive)
• Monterosso et al misclassified as positive
• Heimer et al does not measure prevalence in a
  population of IDUs, but only in returned needles

53
Comments on Wodak et al report

• Ljungberg et al compares HIV prevalence in Lund
  and surrounding areas with NEP introduced in
  1987/1988 (without a severe epidemic)
• with Stockholm, without NEP, that had an rapid
  phase in 1983-85 with a prevalence of around 50
  among heroin injectors
• ignoring that by the time of the study HIV
  incidence was already down to around 1 in
  Stockholm

54
Comments on Wodak et al report

• With these corrections the case stands
• 3-7 - not a very strong case for NEP

55
Conclusion

• NEP has not been shown to be very effective in
  preventing HIV among IDUs
• Well established tools like HIV testing and
  counselling, contact tracing etc seem to have
  been neglected in many places
• Perhaps as a result of the overemphasis of NEP

56
(No Transcript)
57
Combating Drugs a World Challenge Kova su
narkotikais pasaulinis iukis June 1-2,
2006 VILNIUS
58
(No Transcript)
59
Drug-related deaths a problematic definition

• Anna Fugelstad

60
A problematic definition
61
Drug Related Deaths (DRD)An important public
health problem

• The deaths mainly affects young people
• DRD is a leading cause of death among young age
  groups in many countries
• The deaths are unnecessary and preventable
• The number of DRD is regarded as the best
  estimator of the magnitude of the illicit drug
  problem in a society

62
Which drugs are included in DRD?

• Various opinions about what to include e.g.
  dextropropoxyfen, methadone, bensodiazepines or
  anabolic steroides
• In the studies presented here only illicit drugs
  as heroin, amphetamine, cocaine, cannabis, LSD
  and some synthetic analogues are included

63
Definition of drug-related deaths

• Deaths which should not occurred if the subject
  was not under influence of illicit drugs or a
  long term misuser
• Both sudden deaths in connection with injection
  and intoxication, accidents, suicides and HIV and
  other infections in connection with drug use were
  included

64
How is the information obtained about DRD in
Europe?

• A cause-of-death investigation is made, and a
  death certificate is issued the extent of the
  investigation varies among the European countries
• A death certificate is sent to the national
  authority in charge of cause-of-death statistics
• The information on causes of death is coded
  according to the ICD-rules (International
  classification of diseases) each case gets one
  or more ICD-codes
• There are great variations between European
  countries regarding what information is possible
  to obtain when the cause of death is coded

65
Where is it possible to find information about
DRD?

• All European countries have General Mortality
  Registers (GMR) which cover 90-99 of all deaths
• EMCDDA (European Monitoring Centre for Drugs and
  Drug Addiction) provides a selection of ICD-codes
  which classify a death as drug-related. There are
  also national classifications.
• In some countries there are Special registers on
  drug-related deaths based on forensic medical
  investigations

66
Special register based on forensic medical
investigations

• In Sweden and Finland all acute drug related
  deaths undergo forensic medical investigation,
  which includes an examination of the dead body, a
  toxicological investigation and a description of
  the circumstances around the death
• The toxicological investigation includes illicit
  drugs, prescribed drugs and alcohol
• The frequency of forensic investigations varies
  among European countries. In the Netherlands this
  type of investigation is only performed when a
  crime is suspected, in Sweden and Finland it is
  made in most cases of unnatural death

67
Which type of register gives the most relevant
information?

• Special registers based on forensic medical data
  often give better information about the single
  cases of death
• This information can be used a tool for
  prevention
• The information can be obtained soon after the
  death
• General mortality registers which cover the whole
  country often give better information on
  drug-related mortality trends
• However, there is little information about the
  single deaths. It is difficult to distinguish
  between legally prescribed drugs and illicit
  drugs and the precision is low

68
Is it possible to investigate all drug related
deaths?

• It is difficult to do this as a routine procedure
• There are a number of different substances which
  are related to death in various ways
• Special registers do not cover deaths with a
  considerable time lag i.e. AIDS and Hepatitis
• A total investigation of drug related deaths can
  probably only been made as a research project
  during a limited time period and geographical
  area

69
Study 1Causes of death in relation to different
illicit drugs
70
The Stockholm register an attempt to make a
total investigation

• All known drug-related deaths in the Stockholm
  area 1985-1996 were investigated
• Objectives
• Increase the knowledge of risk situation and
  causes of death in relation to different drugs
• Study the trends drug-related mortality and
  causes of death over time
• Evaluate the Swedish GMR by studying how many of
  the deaths got a diagnose related to drug-related
  causes in the official statistics
• Estimate the total number of drug-related deaths
  in the region

71
Which deaths were classified as drug-related in
the Stockholm register?

• Medico-legally investigated deaths with presence
  of illicit drugs in the dead body or history of
  drug abuse in the catchment area of the Stockholm
  department of forensic medicine
• All known deaths among HIV-positive persons who
  were i.v. drug addicts in all clinics for
  infectious diseases in the Stockholm region
• All deaths which occurred in hospitals in the
  Stockholm region with a drug-related cause of
  death in the GMR

72
Classification according to main type of illicit
drug

• If heroin (morphine) was present, the death was
  classified as heroin-related
• If heroin was absent but amphetamine was present,
  the death was amphetamine-related
• Cocaine and other substances were classified
  accordingly (not further described due to few
  cases)
• If only THC (a cannabis residual) but no other
  illicit drugs were present, the death was
  classified as cannabis-related

73
Heroin(morphine)
The majority of the deaths were in connection
with heroin injection followed by natural causes
74
Risks in connection with heroin

• Heroin and morphine are highly toxic and
  therefore often involved in acute intoxications
• Are mostly injected risk for bacterial and
  viral infections
• But no damage of other bodily organs even after
  long-term use
• No main influence on mental functions after
  long-term use

75
Heroin intoxications so called overdoses

• The concentration of morphine (the main heroin
  metabolite) after death is often low
• Very often there is a combination with alcohol,
  prescribed drugs or other illicit drugs
• Also snorting and smoking heroin may cause fatal
  intoxications
• There is a risk for aspiration often with fatal
  outcome

76
When is the risk for a fatal heroin intoxication
increased?

• Beginners in connection with their first
  injection
• Alcohol-intoxicated persons who try to inject
  heroin
• After involuntary intermissions in heroin use
  e.g. after incarceration
• After voluntary intermissions
• Relapses among rehabilitated addicts
• Amphetamine or other drug users who take the
  wrong drug

77
Amphetamine
The majority of deaths were accidents under the
influence of amphetamine and death due to natural
causes
78
Amphetamine

• In Sweden amphetamine users are the oldest drug
  addicts many have used the drug for more than
  30 years
• The highest rate of natural deaths infections
  and cardio-vascular deaths are common
• Many deaths are related to a criminal life-style
  or to psychotic episodes
• Fatal traffic accidents are common in this group

79
Risks in connection with amphetamine

• Causes organ damage during long term use i.e.
  cardio-vascular lesions
• Influences mental functions, causes behavioral
  disturbance and drug-related psychoses, often
  with paranoid ideas
• Amphetamine alone seldom causes fatal
  intoxications

80
Cannabis
The majority of cases were suicides under
influence of THC. The majority of accidents were
probably alcohol-related
81
Cannabis

• Some very violent and impulsive suicides and
  homicides were found in this group
• Some of the suicides were in connection with
  relapse into a psychosis triggered off by drug
  use
• Other suicides were in connection with depression
  and chronic cannabis use
• Fatal traffic accidents occurred in connection
  with a deluded reality perception

82
Risks in connection with cannabis

• Strong influence on mental functions. Risk for
  cognitive disturbances and psychoses. Relation
  between cannabis use and schizophrenia
• Generally no organ damage with the exception of
  an increased risk for lung cancer
• No serious acute intoxications

83
Infections transmitted in connection with heroin
and amphetamine injection

• Very few new cases of HIV among Swedish i.v. drug
  addicts after 1985 (ambitious testing programmes
  a possible reason)
• Hepatis C very common among i.v. drug users
  increased risk for cirrhosis and liver cancer
• Some cases of bacterial infections with damage of
  cardiac valves

84
Presence of alcohol in different drug groups
Heroin deaths 59 alcohol Amphetamine 38
alcohol Cannabis 71 alcohol
85
Deaths from natural causes increased over time
86
The average age increased over the study period
87
Study 2Deaths with presence of illicit drugs in
Sweden 1994-2005
88
Background

• The Swedish official cause-of-death register
  covers 99 of all deaths
• However, a significant drawback is that there is
  a 2 year delay in publishing the statistics
• 20 of the DRD in the register are not related
  to illicit drugs many occur among persons
  without any history of drug abuse e.g. suicides
  among elderly people using legally prescribed
  morphine

89
Objective

• To establish a new register,
• that is not based on assessment and coding of
  death certificates
• where the information is available after a short
  time period
• that covers the whole country

90
Data from forensic medical examinations

• In Sweden, 93 of violent deaths and
  intoxications are subject to forensic medical
  examinations
• A toxicological investigation is made in a
  majority of the cases
• Illicit drugs are examined in all cases where the
  presence of such drugs is suspected or cannot be
  excluded
• The information is available in a national data
  base

91
Method

• All deaths, with presence of illegal drugs were
  collected from the toxicological database at the
  central board of forensic medicine
• The deaths were classified according to the
  dominating drug in the following order
• Morphine
• Amphetamine
• Cocaine
• Other defined illicit drugs
• THC
• The heroin/morphine cases were classified into
  acute heroin deaths and morphine/heroine deaths
  depending on the presence of 6-acetylmorphine

92
The overall trend shows a slight decrease after
the year 2000
93
Splitted into different main drugs the figure
gives more information on actual trends
94
How to interpret the trends?

• The heroin group probably covers all acute
  overdos deaths in Sweden and trend reliable
• The amphetamine deaths are probably
  underestimated. Many amphetamine users die from
  natural causes and therefore not included in a
  register based on forensic data
• Cannabis is probably overestimated and shows an
  increased use in society. Many of these deaths
  are probably alcoholrelated

95
Two metropolitan areas (Stockholm and Malmö) are
dominated by heroin deaths In the rest of Sweden,
including Gothenburg, amphetamine deaths dominate
96
Conclusions
97
Difficult to predict mortality from drugs

• Drug-related deaths is a very broad concept and
  includes several types of drugs which can be
  fatal in many different ways
• The same drug may cause immediate fatal
  intoxications and contribute to chronic
  infections which may lead to death after many
  years
• The present pattern of drug use is a rather new
  phenomen and there is a lack of knowledge about
  the long term effects

98
Various patterns of death

• The main causes of death, related to illicit drug
  are changing over time
• In New York heroin-related deaths was replaced by
  cocaine-related death in the 1990s. Today heroin
  is back
• In Spain AIDS was the major cause of death among
  drug addicts in the late 90s. Today cocaine is
  an increasing problem
• In Sweden more amphetmine users die from chronic
  disease after decades of drug abuse

99
Heroin use is problematic

• Heroin often causes unexpected fatal
  intoxications which are difficult to prevent
• Even drug-free treatment may increase the risk
  for fatalities in connection with relapses as a
  result of lowered tolerance
• Methadone may cause fatalities because of its
  toxicity
• A number of deaths have occurred when methadone
  has been sold at the black market instead of
  being used in treatment
• Many countries have suffered from large problems
  because of methadone deaths

100
Cannabis

• Cannabis has not been regarded as a dangerous
  drug but may cause drug-related psychoses and
  confusions
• A number of deaths have been related to such
  events.
• Cannabis-related psychoses may be unusual but
  cannabis use is very common and increasing among
  young people

101
International comparisons problems and
possibilities

• It is important to exchange information on
  drug-related deaths and risks between countries
  and to strengthen the ability to meet new trends
• EMCDDA makes surveys of the trends in DRD in
  European countries and has shown that
  heroin-related death seems to decrease in many
  countries
• As the frequency of forensic medical
  investigations and the ability to obtain data on
  DRD varies among countries it is not possible to
  make international comparisons of the numbers of
  drug-related deaths

102
(No Transcript)
103
Corruption a Hinder for the Fight against
Drugs
104
Corruption as Impediment in Fight against Drugs

• Andrejs Vilks, Director of
• ECAD in Latvia

105
Where is the policeman rushing to?
106
Definitions of Corruption

• The application of vested authority and rights by
  officials for the personal profit.
• The use of public opportunities for the private
  interest (Makiavelli)
• The abuse of ones authority in order to gain
  personal profit (UNO Materials)
• In Roman Law corrumpire was understood as to
  damage, to destroy, to spoil, to falsify, to
  bribe and meant illegal action.
• Requesting, offering, giving or accepting,
  directly or indirectly, a bribe or any other
  undue advantage or prospect thereof, which
  distorts the proper performance of any duty or
  behaviour required of the recipient of the bribe,
  the undue advantage or the prospect thereof (EU
  Materials)

107
The Size of Drug Corruption

• According to the data from the experts 800
  billions of USA dollars are involved in the realm
  of drug business annually.
• The results of the research which has been made
  by the World Bank Institute indicate that the
  quantity of bribes paid off all over the world
  compose 1 trillion of USA dollars annually.
• Approximately 400-500 billions of USA dollars can
  be expended on drug corruption annually.
• The facts about drug corruption in general are
  latent (less than 1 of them become known to law
  enforcement institutions).

108
Corruption Hallmarks

• Conscious subjugation of officials mutual
  benefit to personal gain.
• Confidentiality of decision fulfilment.
• Reciprocal undertakings between decision-making
  officials and those who take the advantage of it.
  
• Co-operation between those who need particular
  decision to be made and those who can affect the
  making of this decision.
• Attempt to hide the corruption with any legal
  justification.
• Performance of dual functions public and
  private.
• Plunderage, misappropriation of the state
  property by officials
• - misuse of authority for the unjustifiable
  personal profit.
• - conflict of interests between liability and
  personal gain.

109
Drug Crime Tendencies and Corruptibility

• Close connection between corrupted dignitaries
  and criminal (drug criminal) environment
• Aspiration of drug criminal groups to cooperation
  with officials and even to establishing of mutual
  business
• Organisation of new types of transnational
  criminal groups tending to close cooperation with
  government body.

110
Factors Determining Drug Corruption
111
Forms of Corruption and Drug Corruption
112
State Capture

• State capture purchase with powerful
  (financial, economical, criminal, etc) resources
  of the decisions made by officials or public
  authorities.
• Types of state capture which may be connected
  with corruption in the sphere of drug addiction
  
  - parliament capture (granting of
  privileges and particular posts to the members of
  parliament creating of manageable body of
  deputies).

113
State Capture

• Purchase of laws, changes in legislative acts,
  parliament decisions and agreements
• Development and acceptance of laws enabling
  corruption
• Purchase of judicial authorities and the
  representatives of judicial body (making the
  decisions in judicial practice in favour of
  business structures dealing with drugs and
  drug-cartels.

114
Corruptibility of Laws and Legal Regulations

• Ability to establish such interrelations among
  subjects of law which increase probability of
  subjects participation in corruption process
  (enhance the bounds of subjectivism while making
  the decision).

115
Probability of Corruptibility of Laws and Legal
Regulations

• Paragraph 253 of Latvia Criminal Code foresees
• the responsibility for illegal production,
  purchase, transfer and transmission of drugs up
  to 7 years of imprisonment with or without
  forfeiture of property (First part of paragraph).
• Illegal distribution and trafficking of drugs
  results in imprisonment up to 10 years with or
  without forfeiture of property police control up
  to 3 years (second part of paragraph)

116
The Corruption of Executive Body

• Capture of high legislative body (Cabinet and
  Council of Ministers, Ministries, Premiers)
• -Making non-effective decisions in fight against
  drug addiction
• Accepted laws, governmental decisions, national
  and international programmes are not ensured with
  necessary resources (technical, financial,
  material). The implementation of programmes
  dealing with fight against drugs on the paper.

117

• Government of Russian Federation in May, 2004
  adopted the decision to enlarge the quantity of
  drugs which intend criminal liability (e.g. 1
  gram of heroin).
• With the order of the president of Russian
  Federation in January, 2006 the changes in
  paragraph 228 of Criminal Code have been made
  (amendments about large and extra-large amounts
  have been carried out)

118
Politics Corruption

• In 2004 the heroin market turnover in Afghanistan
  made 25 billions of USA dollars in 2005 30-32
  billions of USA dollars.
• The president of Afghanistan - Hamid Karzai
  avowed that heroin, which makes 60-80 of
  Afghanistan GDP, demonstrates that Afghans are
  not the nation of paupers.

119
Politics Corruption

• Government compensation for the destructed
  hectare of opium poppy comprises 1250 USD
  dealers offer 16000 USD for the hectare ( there
  are 2-3 harvest per year)
• In 2004 225 000 hectares of soil were sowed with
  poppy
• Bolivia ?vo Morales Panama Manuels Norjega.

120
Politics Corruption

• From the year 1997 there have been 10 criminal
  cases brought against ex Prime Minister of Italy
  - Silvio Berlusconi, among them bribery of the
  judge and finance police.

121
Hierarchical Model of Drug Corruption on
Different Social Levels
On high levels of social system the risk (and
possibility) of corruption is low, however it is
compensated with the large amount of corruption
actions (deals, privileges, presents).
On low levels of social system the risk (and
possibility) of corruption is high, however the
amount of corruption actions is little which is
compensated with the frequency of bribery.
Legislative level
Law-Enforcement Level
Government of customs, border enforcement agency
and police
Institutions of customs, border enforcement
agency, police and health service organisations
Customs officers, border-guards, policemen,
medical and pharmaceutics staff
122
Corruption in Institutions Which Fight against
Drug Crime

• High risk of being corrupted (huge circulation of
  finances and another resources political and
  administratie pressing from legal political and
  administrative governing institutions)
• Heads of the institutions are the objects of
  constant observation by organised criminal
  groups
• Heads of the institutions are the objects of
  constant confrontation, psychological and
  emotional tenseness, blackmailing, menace
• Heads of the institutions are the objects of
  involvement in business relations, bribery, etc.

123
Drug Corruption in Police

• Violation of rights during the investigation and
  during the apprehension
• Appropriation of the goods and financial
  resources which belong to drug dealers
• Distribution of confiscated drugs
• Protection of structures dealing with drug
  business
• Falsification of accusation
• Presentation of falsificated applications
• Use of operative research resources for private
  purposes.

124
Drug Corruption in Police

• Vallo Jäärats, former head of the drugs unit of
  Estonias Central Criminal Police, has been on
  trial himself on charges of committing drug
  crimes and the abuse of his authority in March,
  2006. He has been condemned to 4 years of
  imprisonment.

125
The essence of the crime done by former head of
the drugs unit of Estonias Central Criminal
Police.

• According to the accusation V.J. while being a
  head of the drugs unit of Central Criminal
  Police, on the 21st of June, 2002 has found out
  about the operation dealing with the fight
  against drugs Juliett, performed by the police of
  Finland and Estonia, and has informed about this
  operation I.P., who, in his turn, warned the
  Finnish criminals and, as a result, the operation
  failed.
• Besides that, V.J. was accused in the conveyance
  of confidential information to R.P. from police
  data base, in exchange for the different
  privileges.
• Moreover, V.J. was accused in the purchasing
  from R.P. of 200 grams of cocaine and resold it
  to Parmasto. Accordingly, P. was also accused in
  the drug realisation.

126
Drug Corruption in the Police of Latvia

• In Riga regional court the process on the
  policemen-drug dealers case proceeds, where 10
  ex police officers are involved. Ex-policemen are
  sued for several articles, among which there are
  illegal purchase and keeping in large amounts of
  drugs and psychotropic substances with the
  purpose of realisation (drugs were distributed
  even among the colleagues-policemen at a
  discount). Policemen were also on charges of
  extortion, bribery, etc. Policemen demanded
  bribes from the apprehended people. Bribe size
  was from few hundreds to several thousands of
  lats.
• Prosecutors office submitted to the court 11
  volumes of criminal case.

127
Drug Corruption in the Police of Lithuania

• In 2004 in Klaipeda two officers of patrol-guide
  duty were detected of amphetamine realisation in
  large amounts and criminal proceedings were
  instituted against them.

128
Drug Corruption in Pharmaceutical and Medical
Institutions

• V.L., 49 years old, co-owner of several companies
  dealing with the medicaments LV Pharma, Pharma
  Plus, JEL, Aptieka Rudens 1, Rudens Plus, Aptieka
  Rudens 8, Aptieka Rudens 10, Larusan etc. in
  May,2005 offered the employer of the institution
  against corruption 50 thousand lats (85000 EUR)
  for the discontinuation of the verification of
  his company because of the state orders.
  Secondly, he requested to stop verification of
  the officials of Health Care Ministry. Third, to
  protect the company bribe 50 000 lats plus
  monthly pension 1000 of lats for the employer
  of the institution is the record for the
  independent Latvia.
• The director of State Drug Agency in 10 days
  after apprehension of L. wrecked in car accident.
  Agency have been announcing the competitions on
  state orders of medications, and psychotropic
  substances. In the majority of cases the
  companies under V.L. management won in these
  competitions.

129
Drug Corruption in Pharmaceutical and Medical
Institutions

• On the 27th of March, 2006 Riga regional court
  has begun to examine the criminal case, where
  J.O. is sued for illegally written out recipes on
  large amount of natrium oxibutirate
  psychotropic substance used for the anaesthesia
  (38 324 criminal episodes proved). Moreover,
  content of the ampoule can be used for drug
  intoxication. In December, 2004 J.O. has written
  out the recipes for the reception of 22 000
  ampoules of natrium oxibutirate.

130
Drug Corruption in Pharmaceutical and Medical
Institutions

• During the period from 1999 2004 a doctor has
  written out more than 19 000 recipes to the not
  existing patients. This gave the possibility to
  Orbidan to purchase less than 3 lats per packing
  of natrium oxibutirate as if for the patients.
  Further he sold the substance for 15 lats. At his
  apartment 1500 ampoules of natrium oxiburate have
  been found with value 22500 lats (38000 EUR)
• According to the data from experts there are at
  least 5 doctors in Latvia who similarly abuse
  their authority to write out illegal recipes on
  large amount of drug substances.

131
Bank Credits and Internet are Used For the
Creation of Drug Laboratory

• In 2005 in Yaroslavlj (Russian Federation) two
  men after getting acquainted in the Internet with
  the procedure of establishing the laboratory for
  the production of drugs, have created a
  greenhouse in private apartment and with the
  appliance of modern technologies moved on to
  cultivating the marijuana (the seminal have been
  purchased through the Internet as well). For the
  development of business there have been received
  a credit from the bank (100 000 RUR).
• Similar case has been stated in Latvia.

132
Drug Corruption in Moscow

• In May, 2006 two policemen and three officials
  from drug control institution have been
  apprehended for the creation of organised crime
  group dealing with extortion and abuse of their
  authority beating of and money extortion from
  the drug dealers.

133
Drug Corruption on Municipal Level

• In 2002 E.D., who was a son of local drug dealer,
  has been elected as a deputy for the Caunas
  municipality.
• In 2003 E.D. was apprehended for the
  participation in the activity of organised crime
  group dealing with the production of synthetic
  drugs and counterfeiting of money. He has been
  condemned to 6 years of imprisonment.

134
Drugs and Corruption are United
135
Thank you for your attention !
136
(No Transcript)
137
Combating Drugs a World Challenge Kova su
narkotikais pasaulinis iukis June 1-2,
2006 VILNIUS
138
(No Transcript)
139
Best practices of Klaipeda Municipal Government
140
Best practices of Klaipeda Municipal Government

• Head of Health Care Division
• Municipality of Klaipeda
• Vilnius,2006

141
Formation of the public health care policy is
preconditioned by

• ideological changes,
• legal acts,
• priorities,
• financial possibilities

142
While solving problems related to illegal drug
abuse, Klaipeda City Municipality gives

• a priority to primary prevention - it is aimed
  at decrease of drug addiction ,
• quality personal health care services for the
  people ill with dependence ,
• organization of a good access to rehabilitation
  services,
• reduction of harm caused by drug abuse to non-
  motivated drug-addicts and society

143
The municipality carries out

• the functions of a customer,
• it organizes,
• coordinates,
• makes decisions,
• finances,
• carries out supervision.

144

• The municipal drug control commission is a
  standing commission coordinating drug control and
  drug addiction prevention actions in the
  territory of the municipality

145
The role of the City in the field of drug abuse
prevention
NGOs
Police
Services of Psychologists at schools
Childrens Crisis Centers
Mass media
Rehabilitation Center of Drug Addicts
Childrens Protection Service
Education Division
Klaipeda City Commission of Drug Abuse Control
Home for Independent Living
Klaipeda Psychiatry Hospital
Division of Social Assisstance
Health Care Division
Labour Exchange
Family doctors
Boarding Home
Center of Mental Health
Center for treating dependence diseases
Health care institutions
Center of Public Health
Labour Center for the Disabled
Anonymous Consulting-rooms
146
Primary prevention

• education programs at educational institutions,
• personal consultations,
• the assistance and information telephone line
  Consolation line ,
• the website of Public Institution Center of
  Mental Health
• services for children from risk families
  organized in the center of childrens crises,
• organization of alternative occupations,
• childrens summer caps,
• the program for childrens crime prevention

147
Early drug abuse-dependence diagnostics

• the services of a psychologist,
• a social worker,
• a possibility of testing for the possible drug
  addiction,
• services of day centers,
• a mobile service for street children,
• a temporary home when needed.

148
Where people should apply ?
149
The second and tertiary prevention

• an out-patient and hospital treatment.
• The tactics of a treatment is solved
  individually, depending on the age of a patient,
  the length of being ill, accompanying somatic
  diseases. Initially drug free treatment is
  prescribed, when the illness progresses or for
  people with HIV, an alternative therapy with
  methadone is prescribed. At the hospital
  Minessota treatment model according to the
  program of 12 steps is applied.

150
The alternative methadone treatment

• has been applied since 1995
• Till 2005, 235 patients have been give the
  treatment by this method -
• 10 per cent of the patients did not use drugs at
  all, the remission is from 1 to 7 years.

151
Rehabilitation and Reintegration

• Klaipeda City buys the social labour
  rehabilitation service in Siauliai region in the
  fund Agapao,
• supports financially two rehabilitation
  communities, where klaipedians live,
• services rendered by social workers,
• self-assistance groups.

152
(No Transcript)
153
Major principles of the harm reduction philosophy

• pragmatism,
• human values,
• orientation to harm reduction for society an non-
  motivated abusers,
• keeping a balance between the expenditure and the
  benefit,
• the priority of urgent goals.

154
Harm reduction program

• In Klaipeda a reduction of harm program has been
  under implementation since 1997 after an
  anonymous room of consultations with syringes and
  needles exchange had been established. This was a
  response to the danger of spreading of HIV among
  intravenous drug addicts

155
Harm reduction program

• In 2001, the operation of Klaipeda Anonymous
  Consulting-room was presented in a publication of
  the United Nations Drug abuse and HIV lessons
  to learn as an example of good practice.

156
(No Transcript)
157
Number of Clients in ACR in1997 -2005
158
Giving out and collection of syringes
159
Visits to Anonymous Consulting-rooms
160
Dynamics of HIV spreading in Lithuania and
Klaipeda
161
The things youve been creating for years can
be destroyed in a while. But nevertheless keep
creating Mother Therese
162
(No Transcript)
163
New Fashion
164
Project
NEW FASHION

• Afterclass Education and Youth affairs
  subdivision of Education Department
• Vilnius City Municipality
• Patron of the Project Mayor of Vilnius City
  Arturas Zuokas
• Project has been prepared by senior specialist
  Linas Karalius

165
Objectives of the Project

• To reduce the number of students that take drugs
  and stimulants.
• To inform students about the damage to health
  caused by drug and alcohol abuse.
• To propagate a healthy life style among young
  people.

166
Description

• In 2005, Vilnius City Municipality published two
  attractive colored references about the damage to
  organism and danger to the young peoples health
  caused by drugs and alcohol
• In 2005-2006, the social publicity campaign
  against drugs, alcohol and smoking has been held
  all over Lithuania.
• In 2005-2006 preventive events NAUJA MADA (New
  Fashion) have been organized in educational
  institutions under control of Vilnius
  Municipality. During events, famous and
  well-known artists among young people, presents
  books, lectures about the damage to organism
  caused by intoxicants, and lead discussions with
  students about a fashionable healthy life style.
  
• The Project has started in Vilnius City. After
  municipalities of other cities present proposals,
  the Project will spread all over Republic.

167
The first DIDELE MELYNA KNYGA APIE NARKOTIKUS
(Big Blue Book About Drugs)

• Due to the poor financing, the most of the
  references for students designed for drug
  prevention are printed on a poor quality paper
  and the information is presented in a
  matter-of-fact way only with a very few pictures.
  The information presented in such way is
  unattractive especially for junior students.
• DIDELE MELYNA KNYGA APIE NARKOTIKUS (Big Blue
  Book About Drugs) a colored educational book
  about the effect of drugs and the damage caused
  to the organism. A big amount of colored pictures
  in the book make information attractive for the
  junior students.

168
The second DIDELE MELYNA KNYGA APIE ALKOHOLI
(Big Blue Book About Alcohol)

• According to the last statistical data, 97,8 of
  students take alcohol. It is due to the fact that
  children live in the surroundings where alcohol
  is inseparable part of the national culture.
  There is a lot of alcohol and drug promotion on
  television and in movies.
• Insufficient practicable information for young
  people about the danger of taking stimulants.
• This book presents the information about the
  damage of alcohol to people health and
  development in a playful way.

169
Social promotion

• People of the show world that lead a healthy
  life style and are well known among young people
  have been involved in social promotion

Andrius Mamontovas
Linas Karalius
Geltona
Alanas Chonau
SATI
170
Social promotion

• Social promotion posters with the slogan
• THEY HAVE CHOSEN A HEALTHY LIFESTYLE
• have been placed on promotion stands all over
  Lithuania.

171
Andrius Mamontovas,

• the leader of well known band LT United, which
  has represented Lithuania in an annual Eurovision
  Song Contest has also taken part in the project.

172
Events at schools

• The famous and well-known artists among young
  people visited educational institutions of
  Vilnius City where they had lectures about the
  causes of physical and emotional stimulant
  dependence, told about their drug-addicted
  friends harrowing experience, held discussions
  about a new fashionable healthy life style, and
  presented new books.

173
Scope of the Social Promotion

• 25 Models in all newspapers of the Republic
  publication group
• 80 broadcasts on TV3 television.
• 150 radio broadcasts on RADIOCENTRAS.
• Displaying of promotion posters on 135 JCDecoux
  promotion stands and in 300 stops of public
  transport.

174
A newly designed internet portal www.naujamada.lt

• On this website, the students all over Lithuania
  can get acquainted with the Project NAUJA MADA
  (New Fashion), ask specialists questions
  concerning drugs and watch various preventive
  movies.

175
Social promotionfor 2007 year
www.naujamada.lt
176
Sati
177
(No Transcript)
178
Meiktu dvaras rehabilitation center
179
(No Transcript)
180
Mano Guru program for integration of former
drug addicts
181
Programme on professional skills training for
individuals addicted to drugs
Arturas Melianas Deputy director of Vilnius City
Municipality Health and Social Security
Department Head of Social assistance division
182
Programme on professional skills training for
individuals addicted to drugs

• Objectives to motivate persons addicted to
  narcotic substances to take an active role in the
  labor market, to insure them legal income and to
  provide them training of professional skills in
  the field of public catering services (salad bar
  Mano guru) .
• Programme duration 6 months.
• The programme is carried out in a salad bar Mano
  guru run by the public enterprise Socialiniai
  paramos projektai (Social Support Projects).

183
Social partners

• Vilnius city municipality
• Vilnius Center for addictive disorders
• Virupis, Ltd

184
Stages for successful integration into society of
individuals addicted to the narcotic substances

• Detection (identification of intoxication by
  alcohol, drugs and other psychoactive
  substances)
• Treatment (counseling of out-patients and their
  family members, treatment prescription,
  substitutional therapy, detoxication, treatment
  of in-patients)
• Rehabilitation (medical, psychological and
  social)
• Integration (application of knowledge, obtained
  during rehabilitation, in the daily life) .

185
Steps during the programme
Motivation of the target group to take active
part in the labor market
Primary selection of the programme participants
Employment at the salad bar Mano guru in the
position of a barman, waitress, chef 6 months
contract psychological and social counseling
during the whole programme vocational training
and certification of acknowledged competences
2 weeks trial period in the salad bar Mano guru
Reference letters and support in finding new
employment place
186
Responsibility

• The municipality
• responsible for collaboration of all social
  partners taking part in the programme
• - has provided premises and partial financial
  support to run the programme.

187
Innovation

• This form of problem solution and activity
  organization is stimulating partners to solve
  problems not only basing on internal skills and
  resources but also to involve other concerned
  sectors as local authority, business, NGO.

188
Achieved results

• Since the salad bar Mano guru has been open on
  August 18, 2004 in the programme participated 29
  persons addicted to drugs from 6 rehabilitaion
  communities
• 11 participants have successfully completed the
  programme and got a new job
• at the moment there are 13 participants in the
  programme
• 5 participants have not completed the programme
  due to relapse.

189
Achieved results

• Innovative practice has been positively evaluated
  by the European Community initiative EQUAL
  programme financed by European Social Fund and
  got a grant to develop started activities
• as a result a project Overcome addiction was
  started that naturally supplements prior
  activities
• the project has joined Vilnius cooperative
  college which organizes theoretical training and
  acknowledgement of gain competences.

190
Achieved results

• The programme has been awarded as the most
  original one on the Lithuanian championship final
  f social services organized by
• Lithuanian Association of Social Workers
• Vilnius city municipality
• Ministry of social affairs and labor

191
Visit us ?

• Non smoking
• Alcohol is not served
• Calm relaxed atmosphere
• Salad bar Mano guru
• Vilniaus st. 22/1, Vilnius, Lithuania

192
(No Transcript)
193
(No Transcript)