Abstract
Objectives:
In the late 1990s, when the current Russian opioid epidemic began, illicit opioids used in Russia consisted almost exclusively of heroin. The type of opioids used has evolved in the early 21st century. The objective of this study was to describe the evolution of illicit opioid use among people living with HIV (PLWH) reporting recent opioid use in St. Petersburg, Russia.
Methods:
We examined baseline data from four research studies conducted in the period 2004 to 2015 that included PLWH who used opioids [Partnership to Reduce the Epidemic Via Engagement in Narcology Treatment (PREVENT; 2004–2005; n = 17), HIV Evolution in Russia–Mitigating Infection Transmission and Alcoholism in a Growing Epidemic (HERMITAGE; 2007–2010; n = 281), Linking Infectious and Narcology Care (LINC; 2013–2014; n = 119) and Russia Alcohol Research Collaboration on HIV/AIDS (Russia ARCH; 2012–2015; n = 121)] and describe recent use of heroin and other opioids.
Results:
Although these studies spanned more than a decade, the participants represented similar birth cohorts, the mean age was 24.5 years in 2004 and 33.3 in 2014. The use of opioid types however, evolved across cohorts with the use of any illicit drugs other than heroin increasing from 6% (95% CI: 0.002, 0.29) in PREVENT (2004–2005) to 30% (95% CI: 0.25, 0.36) in HERMITAGE (2007–2010) to 70% (95% CI: 0.61, 0.78) in LINC (2013–2014) to 77% in ARCH (2012–2015) (95% CI: 0.68, 0.84). Any heroin use consistently decreased over the ten-year period in the cohorts from 100% (95% CI: 0.8, 1.0) in 2004–2005 to 54% (95% CI: 0.44, 0.63) in 2012–2015.
Conclusions:
Among PLWH who use opioids from St. Petersburg, Russia, illicit use of opioids other than heroin appears to be more common than heroin use.
Keywords: opioid use, HIV, Russia, PWID
Introduction
Russia is one of the top four countries with the highest burden of illicit drug use as measured by disability-adjusted life years (DALYs) with over 650 DALYs lost per 100,000 population [1]. In the 1990s, there was a rapid increase in the supply of and demand for heroin in Russia as a consequence of social, economic, and psychological factors, in conjunction with the increasing importance of Central Asia as a centre of heroin production and trafficking [2]. This confluence of events contributed to the almost exclusive use of heroin at the onset of the opioid epidemic, leading to a rise in the HIV epidemic in Russia, driven by injecting heroin use [2–4]. Since the late 1990s, the HIV and injecting drug use epidemics in Russia have grown, with estimates of HIV prevalence among people who inject drugs (PWID) increasing from less than 5% prior to 2000 [5] to as high as 60% today [6]. Furthermore, the official prevalence of IDU in Russia is probably an underestimate as a consequence of reliance on data based on “official registration” of PWID [7].
In a 2010 study of IDU in eight Russian cities, injection of commercial heroin was more common than that of homemade heroin in St. Petersburg [6]. Commercial heroin is derived directly from opium, whereas homemade heroin is converted from morphine in local underground laboratories. Data suggest that HIV is more easily transmitted through commercial heroin use than homemade heroin use [8], implying that the type of heroin is important and may have HIV transmission consequences.
Clinicians have noted substantial changes in the type of illicit opioids used in recent years, but published studies on these changes are limited. In a mixed methods study conducted in 2012 and 2013 among PWID in St. Petersburg, 50% of participants (407/811) reported any use of illicit methadone in the past 30 days, compared with only 4% of participants (15/411) reporting having injected methadone in the past 30 days in a 2010 study [9]. Unlike the situation in most parts of the world, where methadone is used as a treatment for opioid use disorders (OUDs), as of 2018, opioid agonist treatment remains illegal in Russia. Methadone is manufactured in underground laboratories from its chemical precursors. Injection of methadone only, compared with injection of heroin only or a combination of both, is associated with fewer injections and thus reduced HIV-related risk. Furthermore, study participants who injected methadone-only were less likely to inject with a previously used syringe [9].
Given the ongoing HIV and opioid use epidemics in Russia, it is important to understand the changes in patterns of illicit drug use, so that treatment and HIV risk reduction efforts can effectively address these trends. The aims of this study were to describe the evolution of illicit opioid use among people living with HIV (PLWH) who use opioids in St. Petersburg, Russia from four cohorts recruited over a ten-year period.
Methods
Participants and study design
The current study focused on baseline data collected from HIV-positive individuals reporting recent (i.e., in the past 30 days) opioid use; Partnership to Reduce the Epidemic Via Engagement in Narcology Treatment (PREVENT; 2004–2005) included 17 participants who met this criterion (9% of all PREVENT study participants) [10], HIV Evolution in Russia–Mitigating Infection Transmission and Alcoholism in a Growing Epidemic (HERMITAGE; 2007–2010) included 281 participants (40% of all HERMITAGE study participants) [11], Linking Infectious and Narcology Care (LINC; 2013–2014) included 126 (36% of total LINC study participants) [12], and Russia Alcohol Research Collaboration on HIV/AIDS (Russia ARCH; 2012–2015) included 121 (35% of total Russia ARCH study participants) [13].
PREVENT:
The PREVENT study was a randomized controlled trial (RCT) to assess the effectiveness of a sexual risk reduction intervention in the Russian narcology (addiction) hospital setting [10]. Participants (n=181) were recruited from two substance use treatment facilities near St. Petersburg. Study activities took place between October 2004 and December 2005. Eligibility criteria for the study included: 1) 18 years of age or older; 2) primary diagnosis of alcohol or drug dependence; 3) no alcohol or other substance use for at least 48 hours; 4) unprotected anal or vaginal sex in the past 6 months; and 5) willingness to undergo HIV testing or a previous diagnosis of HIV infection.
HERMITAGE:
HERMITAGE was an RCT testing a US HIV secondary prevention intervention, adapted for use in Russia to reduce the rates of sexually transmitted infections, unprotected sex, needle sharing, and alcohol use among HIV-positive heavy drinkers [11]. Participants (n=700) were recruited from four clinical inpatient and outpatient HIV and addiction sites in St. Petersburg from October 2007 through April 2010. Eligbility criteria included: 1) 18 years of age or older; 2) HIV-positive; 3) reporting “at risk” drinking levels in the past 30 days (>14 drinks per week or >4 drinks on a single occasion for men, and >7 per week or >3 on a single occasion for women); 4) unprotected anal or vaginal sex in the past 6 months.
LINC:
LINC was an RCT to test a peer-led strengths-based case management intervention to link HIV-positive PWID hospitalized at a narcology hospital to HIV care in St. Petersburg [12]. All 349 participants were recruited from inpatient wards at a narcology hospital in St. Petersburg from July 2012 to May 2014. Key eligibility criteria included: 1) age 18–70 years; 2) HIV-positive; 3) hospitalized at the narcology hospital; 4) history of IDU.
Russia ARCH:
Russia ARCH was an observational cohort study to evaluate the longitudinal association between alcohol consumption and biomarkers of microbial translocation and inflammation. Participants (n=351) were recruited between November 2012 and June 2015 from clinical HIV and addiction sites, non-clinical sites and snowball sampling in St. Petersburg. Eligibility criteria included: 1) 18–70 years old; 2) documented HIV infection; 3) documented ART-naïve status.
It is of note that there was some participant overlap in the cohorts (i.e., 10 individuals participated in both HERMITAGE and ARCH, and 24 participated in both ARCH and LINC). The following were assessed via interviewer-administered questionnaires: demographics, hepatitis C virus (HCV) status, smoking, alcohol use, and drug use. All study participants provided written informed consent. Institutional Review Boards of Boston University Medical Campus and First St. Petersburg Pavlov State Medical University approved all four studies.
Heroin and Other Opioid Use
Information on past 30-day heroin use only, other opioid use only, and heroin and other opioid use was obtained using the Addiction Severity Index (with questions such as, how many days in the past 30 days have you used heroin?) [14], and the Timeline Follow Back method (which used reports of total grams of heroin used on each of the past 30 days) in the PREVENT study [15]. In all other cohorts, recent opioid use was measured using a modified Risk Behavior Survey (with questions such as Have you used heroin by itself in the past 30 days? Have you used other opioids [i.e., codeine, china white, methadone, or fentanyl] by itself in the past 30 days?) [16,17] (Table 1).
Table 1.
Baseline characteristics of cohorts of HIV-positive participants, who reported past 30-day opioid use
| PREVENT (2004–2005) N=17 | HERMITAGE (2007–2010) N=281 | LINC (2013–2014) N=126 | ARCH (2012–2015) N=121 | p-value | |||||
|---|---|---|---|---|---|---|---|---|---|
| Characteristic | No. % | No. % | No. % | No. % | |||||
| Age, mean (SD) | 24.5 (3.6) | 29.8 (4.7) | 33.7 (5.1) | 33.3 (4.6) | <0.0001 | ||||
| Sex | |||||||||
| Male | 10 (58.8) | 165 (58.7) | 86 (68.3) | 86 (71.1) | 0.067 | ||||
| Female | 7 (41.2) | 116 (41.3) | 40 (31.7) | 35 (28.9) | |||||
| Basic education (≥ 9 grades) | |||||||||
| Yes | 16 (94.1) | 214 (76.2) | 125 (99.2) | 112 (92.6) | <0.0001 | ||||
| Employment | |||||||||
| Employed | 11 (64.7) | 170 (60.5) | 43 (34.1) | 42 (34.7) | <0.0001 | ||||
| Not employed | 6 (35.3) | 111 (39.5) | 83 (65.9) | 79 (65.3) | |||||
| Tested positive for HCV | |||||||||
| Yes | - | - | 270 (96.1) | 126 (100.0) | 119 (98.3) | 0.050 | |||
| Injecting drug use history | |||||||||
| Yes | 17 (100) | 274 (97.5) | 125 (99.2) | 119 (98.3) | 0.621 | ||||
| Risky alcohol use, past 30 days (National Institute on Alcohol Abuse and Alcoholism criteria) | |||||||||
| At risk | 6 (35.3) | 246 (87.5) | * | * | 95 (78.5) | <0.0001 | |||
| Hazardous Drinking, Past Year (Alcohol Use Disorders Identification Test) | |||||||||
| Yes | * | * | * | * | 86 (68.3) | * | * | - | |
| Past 30-day Cannabis Use | |||||||||
| Yes | 8 (47.1) | 103 (36.7) | 24 (64.9) | 30 (24.8) | <0.001 | ||||
| Past 30-day Stimulant Use | |||||||||
| Yes | 3 (17.6) | 59 (21.0) | 14 (11.1) | 22 (18.2) | 0.123 | ||||
| Smoking Status | |||||||||
| Regular Smoker | - | - | 190 (96.4) | 121 (96.0) | 118 (97.5) | 0.798 | |||
Data was not collected in that cohort
Statistical analysis
Descriptive statistics (i.e., frequencies and proportions for categorical variables; means, medians, standard deviations, and interquartile ranges for continuous variables) were calculated for key demographic variables, HCV status and all substance use variables overall and stratified by cohort. Chi-square, Fisher’s Exact, ANOVA and Kruskal-Wallis tests were used, as appropriate, to describe differences across cohorts. We obtained exact 95% confidence intervals for the proportions with heroin and any illicit opioid use. Analyses were conducted using the statistical package SAS 9.3 [18].
Results
The baseline demographics and characteristics of each cohort are presented in Table I. The mean age (SD) of participants was 24.5 (3.6) in the earliest study (PREVENT 2004–2005) and increased to 33.3 (4.6) years in the most recent study (ARCH 2012–2015). The majority of participants in the cohorts were male (59% in PREVENT and HERMITAGE, 68% in LINC, and 71% in Russia ARCH). Employment decreased with each subsequent cohort: 35% reported unemployment in PREVENT and 65% in Russia ARCH. The majority of participants completed secondary education across all cohorts.
Alcohol use was common in the cohorts, however the entry criteria for some studies required alcohol use. Past month cannabis use was also common, with 47% reporting past 30 day cannabis use in 2004–2005, 37% in 2007–2010, 65% in 2013–2014, and 25% in 2012–2015. Among the three studies that assessed smoking, over 90% of participants in each cohort were regular smokers. Information on methadone use, specifically, was collected in two cohorts, in 2004–2005, 6% of participants reported past 30 day methadone use, and in 2012–2015, 80% of cohort participants reported methadone use in the past year (Table I).
Use of only illicit opioids other than heroin appeared to increase over time from 0% in PREVENT (2004–2005) to 4% (95% CI: 0.02, 0.07) in HERMITAGE (2007–2010) to 31% (95% CI: 0.23, 0.40) in LINC (2013–2014) to 46% (95% CI: 0.37, 0.56) in Russia ARCH (2012–2015). Furthermore, the use of other opioids in combination with heroin increased from 6% (95% CI: 0.00, 0.29) in PREVENT (2004–2005) to 26% (95% CI: 0.21, 0.32) in HERMITAGE (2007–2010), to 31% (95% CI: 0.23, 0.40) in Russia ARCH (2012–2015). Use of only heroin consistently decreased over the ten-year span from 94% (95% CI: 0.71, 1.00) in PREVENT (2004–2005), to 70% (95% CI: 0.64, 0.75) in HERMITAGE (2007–2010), to 30% (95% CI 0.22, 0.39) in LINC (2013–2014), to 23% (95% CI: 0.16, 0.32) in ARCH (2012–2015) (Fig. I).
Figure 1.
Patterns of Past-30 Day Opioid Use, By Cohort
Discussion
Across four cohorts of PLWH who use opioids recruited over the past ten years in St. Petersburg, Russia, a dramatic decrease of heroin use was observed. Use of opioids other than heroin or a combination of heroin with other opioids has surpassed heroin use alone in the period from 2004 to 2015. Additionally, two social trends were observed: 1) PLWH who use opioids in these studies are aging (mean age of 33.0 in the latest cohort vs. 24.5 in the earliest); and 2) There has been an increase in self-reported unemployment in the cohorts (35.3% in 2004–2005 vs. 65.3% in 2012–2015). The sites or recruitment approaches, including narcology hospitals, an infectious disease hospital, and snowball recruitment do not explain why participants were not similarly aged. The data on ages of PWID are consistent with those of other studies in St. Petersburg, Russia, where the mean age was 23.6 in 2004 vs. 32.8 in 2014 [5].
Public health goals may be better achieved with an understanding of which opioids are used among PLWH. Recent findings from St. Petersburg suggest that street methadone is the most commonly available opioid in the city, and its use is associated with less frequent injections than heroin, and thus reduced injection-related HIV risk [7]. This may in part explain the observed trend of a decrease in injection-related HIV transmission and increase in sexual transmission of HIV in Russia in recent years [19]. In a qualitative study among PWID in St. Petersburg, some reasons participants cited for the initiation of methadone were the disappearance or irregularity of the heroin supply, a drop in the quality of heroin, longer effects of methadone and prevention of heroin withdrawal. Lastly, the need for fewer injections to prevent opioid withdrawal made this drug less expensive [9].
The study has several limitations. First, it is a secondary data analysis and the entry criteria of each cohort were different. Differences in entry criteria and recruitment sites could partly explain the apparent temporal trends that were observed.
Secondly, data on methadone use explicitly were only available in two cohorts, therefore, assumptions were made about “illicit opioids other than heroin” in the other cohorts. Thirdly, cohorts analyzed in this study were from St. Petersburg and the surrounding region, and the results may not apply to other regions of Russia. Lastly, we compared different age groups (mean age 24.5 in PREVENT vs. 33.3 in ARCH in 2015). If the study had a primary goal of exploring the change of substance use patterns overtime and assessed a population with a mean age closer to that of PREVENT participants, the results may have been different.
Despite these limitations, data from this analysis have value, as they reveal a change in the pattern of opioid use that may have implications on injection behavior among PLWH in St. Petersburg. Such data may in part explain HIV transmission patterns in Russia. These findings may be useful in the development of HIV prevention approaches to combat further HIV transmission, as some past interventions have been effective in targeting injection-related HIV risks in St. Petersburg [20].
Conclusion
Among PLWH, who reported recent opioid use from St. Petersburg, Russia, illicit use of opioids other than heroin appears to have eclipsed heroin use in the current era.
Acknowledgments
This work was supported by National Institutes of Health (U01AA020780, U24AA020778, U24AA020779, R01DA032082, R01AA016059, R21AA14821, and P30AI042853). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.
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