“Now it is mostly done through stashes, to do it in person one has to trust you”: Understanding the Retail Injection Drug Market in Dnipro, Ukraine

Abstract

Little research has been conducted in Ukraine since the 1990s to understand the organization of drug market and its implications for people who inject drugs (PWID). In this study, we explore how PWID perceive the retail drug market in a large Ukrainian city. Qualitative data were obtained during in-depth interviews and analyses included open coding, coding tree development and revision, axial coding, and identification of higher-level domains. Participants’ narratives focused on types and forms of drugs available, perceptions about drug quality, methods of buying drugs, and the relationships that are formed and maintained by participating in the drug economy. The described technical organization of the drug market, with multiple contingent combinations of drug types, forms and means of obtaining drugs (hand-to-hand vs stash-based) resulted from diversification and digitalization of the retail injection drug market. The social organization of the drug market in the form of relationships with sellers and drug use partners represented the response to the fundamental problem of uncertainty. The lens of “transaction cost” helps explain strategies PWID used to manage uncertainties, including finding reliable and suitable sellers, sending money and picking up the stash under the threat of being stiffed or caught by the police, choosing the product itself, using the intermediaries to outsource risky operations and forming groups to procure and inject together. Our results indicate that the technical and social organization of drug distribution in Ukraine stimulates formation and continuation of relationships and impacts the choices of what, how, and when to inject beyond individual preferences. The policy and practice implications include the need to monitor and understand the retail drug market to develop and deliver more efficient and client-oriented services, incorporate and leverage social networks structure for information sharing and behavior change, pilot and implement drug testing services to assist with management of uncertainties.

Introduction

For Eastern Europe, the prevalence of drug use is often viewed through the historical lens of the transition period after the Soviet Union collapsed (Booth, Kennedy, Brewster, & Semerik, 2003; Corsi, et al., 2014; DeHovitz, Uuskula, & El-Bassel, 2014; Poznyak, Pelipas, Vievski, & Miroshnichenko, 2002). This period coincided with the shift to “free-market” economics and “globalization” of drug, transport and communication networks (Rhodes, 2002). The immediate post-Soviet period was associated with a rapid and dramatic increase in the supply of illegal drugs combined with an increased demand in the context of declining income, widened income inequities, increased unemployment, and decreased funding for state services (Booth, et al., 2003; DeHovitz, et al., 2014; Poznyak, et al., 2002).

Though opiate use was not new to Ukraine (Poznyak, et al., 2002), concurrent social, economic, and psychological factors led to the increase in the number of people who injected drugs (PWID), which is often used as a proxy for the volume of drug market (Antonopoulos & Papanicolaou, 2010). Further, drug market practices, such as selling pre-prepared drugs (Booth, et al., 2003), which are distributed from one large container to the customer’s syringe have been linked to the HIV outbreak among PWID (Booth, et al., 2003; Dumchev, et al., 2009; Rhodes, et al., 1999; Rhodes, 2002). As a response, increased international donors funding stimulated the development of program-oriented research on the health consequence of drug use among PWID (APH, 2017; Bojko, et al., 2016; Hamers, et al., 1997; McGill, 2016, 2017; Owczarzak, Filippova, & Phillips, 2014). Consequently, in Ukraine, while research on understanding drug use and HIV risk proliferated, there has been little systematic exploration to understand drug market operations (Rhodes, 2002; Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005). Peer review literature mainly used data from late-1990s Ukraine to describe how the drug market context impacted HIV risk behaviors of its actors (Rhodes, 2002; Rhodes, et al., 1999; Rhodes, et al., 2006; Rhodes, et al., 2005). Reports about local drug purchase habits and patterns, and the market impact on everyday drug use behaviors of its actors in Ukraine thirty years after the Soviet Union collapse are still scarce.

Meanwhile, the literature on drug markets attempted to classify these markets into archetypal illegal submarkets according to the type of drugs sold (cocaine, heroin, cannabis, and the synthetics) (Antonopoulos & Papanicolaou, 2010); by the vertical organization (supply and demand) (Potter, 2009); and along the axes of technical and social organization (Curtis & Wendel, 2000). The technical organization of drug markets refers to the physical location, policies, procedures, technology and digitalization, and equipment utilized during distribution (Curtis & Wendel, 2000). The social organization of drug markets includes such characteristics as interaction between actors, strategies for dealing with uncertainty, information asymmetries, perceptions of “risk,” and issues of trust (Curtis & Wendel, 2000). Research on drug markets also recognizes that while drug trafficking is increasingly a global phenomenon, drug markets at the level of end-use are contingent on the types of drugs, those who use them and the historical, social and cultural contexts in which they operate (Antonopoulos & Papanicolaou, 2010; Paoli, 2002; Potter, 2009). Understanding the combinations and variations in these contingencies may distinguish effective policy and interventions to reduce and minimize social and health cost of drug use.

For Ukraine, information on the supply and demand side of the drug market is limited. On the supply side, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) reports that local clandestine production, supported by the cultivation of poppy and subsequent production of acetylated or extracted opium, largely satisfies injection consumption needs within Ukraine (EMCDDA, 2014). However, the Ministry of Interior Affairs data on seizures of illicit substances indicate decreases in seized poppy straw from 4,162 kilograms in 2010 to 452 kilograms in 2018 (CMHMDA, 2019). The most widely used estimate of the volume of the drug market and preferences for types of drugs comes from the population size estimation studies conducted within an HIV surveillance and programming framework (Berleva & Sazonova, 2017). Currently, there are an estimated 350,000 PWID (those who reported injecting drugs within the last 30 days) (Berleva & Sazonova, 2017; UNAIDS, 2019) in a total population of 42 million in Ukraine (StateStatisticsService, 2017). An estimated 80% of PWID report use of opioids (Barska & Sazonova, 2016). On the demand side (retail-level distribution), there is little information about such drug market characteristics as the location of sales, use of communication and banking technology, type of drugs being sold, and social organization of distribution that includes relationships between sellers and buyers (Curtis & Wendel, 2000; Izenberg, et al., 2013; Kutsa, et al., 2016).

Therefore, exploration of the technical and social organization of the retail drug market, behaviors of buyers, and the social context of the drug market operations at the retail level is long overdue. The retail drug market refers to the ‘network in which buyers and sellers interact to exchange’ illegal drugs for money or other material goods or services (Bouchard, 2007). Such investigation may help to find insights into the production of risk for PWID in Ukraine and to develop locally relevant approaches or better adaptation of evidence-based interventions to reduce harms associated with drugs use (Owczarzak, et al., 2014; Rhodes, et al., 2005).

This paper explores perceptions of the drug market, the relationships that are formed and maintained within it, and how the current drug market structures drug purchasing behaviors and interactions with other retail-level actors from the perspective of PWID in one large city in Ukraine.

Methods

Data for this study come from a project designed to examine drug use practices unique to Ukraine as contributors to HIV/HCV risk. We conducted the study in Dnipro - one of the largest industrial centers of Ukraine in the Southeast of the country, with a population of about 1 million people. In 2018, the official unemployment rate was 7.8% among women and 8.2% among men (Dniprostat, 2020).

According to the most recent estimates, there are between 11,000 and 30,000 PWID in Dnipro (Berleva & Sazonova, 2017) with the majority of PWID (73.4%) indicating opioids as their main drug, with opium extract being the most prevalent drug of choice (72%).

We conducted 30 interviews with people who inject drugs in Dnipro in Ukraine between March and August of 2018. Recruitment occurred through direct contact from agencies that provide services to PWID, street-based outreach, and participant referral. To learn from participants with different backgrounds and from different parts of the city, we monitored age and sex distribution, socioeconomic characteristics and district where people lived during data collection and targeted those participants who were underrepresented in our sample.

Eligibility criteria were being 18 years or older, living in the study city, and injecting drugs within the last 30 days. All interviews were conducted at a time convenient for participants in a private room at a local non-government organization (NGO). Eligible participants provided oral consent. This study was reviewed and approved by the Institutional Review Boards at the Johns Hopkins Bloomberg School of Public Health (IRB#00008235) and the Ukrainian Institute on Public Health Policy (Submission id 2017-038-03).

The data collection process consisted of an in-depth, semi-structured interview. The interviewers had a background in psychology and were trained in conducting qualitative data collection through in-depth interviews.

The interview included such topics as PWID daily routines, whether activities were planned or spontaneous, and people with whom participants interacted while moving through their days. Additional questions explored how participants obtain and use drugs and how they feel during these processes. Interviews lasted between 1 and 2 hours.

Interviews were transcribed verbatim, translated from Russian to English, and uploaded to MAXQDA (VERBI, 1989) for coding and analysis. Transcripts were coded and analyzed by AM, JO, TK for emergent themes using principles of grounded theory analysis (Strauss and Corbin, 1990). The analysis took place deductively and inductively by exploring major study domains but remained open to unanticipated themes, patterns, and relationships. The coding tree was developed through an iterative and collaborative process, ensuring reliability and consistency (Carey, Morgan, & Oxtoby, 1996). Qualitative analysis followed a multistep process. First, during open coding, research team members independently read the same transcript and identified and applied preliminary coding categories which included a priori and inductive codes. A priori codes reflected topics and content areas in the interview guide, such as drug use rules and norms, income generation strategies, and daily routines. Inductive codes or themes that emerged from the data but were not explicitly asked in the interview included buying drugs through stashes and hand-to-hand, relationships with drug use partners and sellers, quality of drugs, taking care of self, safety and danger, trust, and staying home. We then formed an initial coding tree and used it to individually code the same interview. After the discussion, the coding tree was revised, and a different transcript was coded using the revised coding tree. The process was repeated until all team members were satisfied with the final coding tree.

The same researchers then independently coded the remaining transcripts with the final coding tree, periodically checking for consistent use of codes. We conducted axial coding after all transcripts were coded at least once. During axial coding, such categories as drug sellers/dealers, drug-use partners, the effect on relationships, drug quality, drug dose, unforeseen circumstances, drug sharing and splitting, safety and danger were explored in relation to drug market category. Higher-level domains were identified and included drug market and characteristics of drugs, drug market and the process of buying/using drugs, and drug market and relationships. Then participants’ experiences and perceptions within these domains were summarized and connected using one sheet of paper exercises during which text segments from the same domain were placed on one sheet of paper followed by a focused review of the domains. Transcripts were also coded by document variables to reflect key sociodemographic and health characteristics. Our dataset consisted of 30 interviews with participants whose average age was 37 years old, 8 of whom were women (Table 1).

Table 1.

Selected Participant Characteristics (N=30)

Characteristics	Number of participants
Mean age	37
Female	8
Have children under 18	9
Have enough to meet basic needs	9
Employed (full-time or part-time)	10
HCV positive	12
HIV positive	13

Results

When discussing their drug use, participants focused primarily on types of drugs available, the form in which they could be purchased, ways of buying drugs, perceptions about drug quality, and the relationships that are formed and maintained by participating in the drug economy. Our analysis showed the technical and social organization of the drug market and how drugs themselves and the ways in which drugs were purchased fostered the creation and maintenance of specific forms of sociality.

The product: type and form

Homemade opioids were the most prevalent substances our participants consumed. These homemade opioids (often called shirka [ширка]) were typically prepared from a concentrated substance called malyas [маляс]. The perceptions of the origins of malyas varied and included poppy, poppy straw, pharmaceutical pills containing opioids, and intermediate products of pharmaceutical production of opioid analgesics. However, participants often were unsure about the origins of malyas and shirka they purchased and speculated about its origins based on the physical appearance of the prepared solution and its effects on their body and mind: “When it’s made from malyas – its color is dark, and when it’s made from poppy, its color is light” [Iryna, female, 30 years old]. Participants also frequently mentioned illegally manufactured crystal methadone - methadone that is sold on the street and visually resembles crystals, availability of which recently increased.

Use of stimulants was less common, but participants repeatedly mentioned them as the drugs they used in addition to opioids or, more rarely, as a preferred drug. Vint – an ephedrine-based drug solution was the most popular stimulant among our participants; at the same time, it was negatively perceived as having more harmful effects on health than shirka, partly due to the belief that it was ‘synthetic’ and ‘not natural.’ Participants also mentioned using different substances that could be bought in pharmacies and added to the primary drug to enhance its effect - for example, eye drops containing tropicamide or antihistamines such as Dimedrol to enhance the drugs’ effects.

Participants obtained drugs in a range of forms, including buying solution ready for injection, buying a semi-manufactured product that required additional processing before the solution could be injected, and buying ingredients from which a solution could be prepared. Availability and preference for these forms depended on the availability of and connection with a seller who offered already prepared drugs, whether the buyer had skills and location to prepare the solution, and price considerations (generally, participants reported that pre-prepared solutions were more expensive). For example, opioids could be bought in a pre-packaged syringe and injected right away, or as a semi-manufactured product (malyas) that required heating and adding chemicals and/or diluting in water, or as ingredients that required more elaborate recipes (pharmacy ingredients).

The delivery: ways of buying drugs

The numerous combinations of types of drugs and forms in which they could be purchased were further complicated by different ways of buying drugs. Participants described two main ways of getting drugs: hand-to-hand and stash-based (zalkadka [закладка]). Descriptions of the mode of operation for buying drugs through stashes were very consistent and included the following steps: calling a trusted number to check whether the drug is available; transferring money through cash transfer machines widely available in supermarkets and elsewhere; confirming the transaction with the seller and receiving instructions about where to find the stash; and picking up the stash.

This stash-based approach is a recent innovation for the Ukrainian drug market, while the hand-to-hand approach is considered an ‘old school’ style that used to dominate on the market but recently became less prevalent. However, both approaches currently co-exist within the drug market in Ukraine. The process of buying hand-to-hand also started with a call to check whether the drug was available that day and followed by several alternative sequences of events depending on the access to the seller, availability of drugs and location of the transaction. Notably, exchanges that occurred in the seller’s apartment required a degree of trust between the buyer and the seller that would make them comfortable to meet in person and exchange money for the drug.

When choosing how to buy drugs, participants considered multiple factors: price, quality, safety, level of control over the process, availability of certain drug types, operating hours, and access to the seller. For example, a person could interchange buying through stashes and buying hand-to-hand if they wanted different drugs (e.g., vint instead of shirka) or a different form of drug (ready-made vs raw), or based on perceived advantages in terms of quality and price, or if one of the approaches was unavailable or they did not have access to a seller from whom to buy in person. Despite several patterns in drug obtaining decision-making described further, the overall process resembled multiple permutations of several possible scenarios.

The decision about whether to buy through stashes or hand-to-hand was also a decision about the form of the drug to be purchased. Buying hand-to-hand most frequently involved getting a single dose of prepared drugs put into a single syringe ready for consumption and ready for immediate consumption (shirka), while buying through stashes often meant getting the semi-manufactured product (malyas) or just the ingredients for which additional preparation was required before the solution could be injected.

Price considerations often were focused around whether a person had a certain amount of money that would cover the purchase of a minimum amount available for sale. The most economical buying option in the long run was buying through stashes because the price per dose was lower. Given the economic precarity in which most participants lived, however, buyers often could not afford to buy through stashes, thus necessitating that they pool money with other buyers.

R[respondent]: If you get drugs just by doses, then you will never have enough money. Because one dose costs 100 hyrvnias [UAH], but I, for example, need 300 UAH per day. This is the minimum to feel normal. And suppose I get drugs not by doses but a large amount—where there is such an option as stashes, when I get not cooked (drugs) but concentrated that must be cooked. Then it will cost me … 500 UAH but this amount will be enough for 3 days…

[Petro, male, 43 years old]

I: Do you buy it alone?

R: No, alone - it is very difficult to do…

I: Why?

R: Because they do not sell in one cube [1 milliliter] now. You need to partner with someone because you have to buy three [cubes] at least and chip in…

[Lubov, female, 34 years old]

On the other hand, purchasing hand-to-hand was more available in everyday situations – a buyer could get the necessary volume for one injection, but the price per dose would be higher compared to buying ‘in bulk’ through stashes. Apart from the issues of form and price, participants also had to consider “operating hours” of stash and hand-to-hand sellers and plan drug use accordingly, to avoid hectic and stressful search across the city. Stash sellers were available during certain operating hours, and hand-to-hand sellers only sold drugs when they had prepared the solution.

R: Sometimes, when I feel very bad, and in the evening, we didn’t get a stash or in the morning… Say, holidays… Stash people, they have a holiday of their own… There are no stashes (laughs). So, throwing money away, paying extra to someone… You lie at home waiting for these stashes… Sometimes, at this drug addict’s [home], the kid who cooks… it happened. We inject there.

[Roksolana, female, 55 years old]

Participants had differential access to drugs depending on their financial ability to buy a a larger amount of drug and planning, and on closeness and reliability of the relationships with the seller.

Considerations of safety were pivotal in defining buying choices and were mostly related to the fears of being followed and harassed by the police. Many perceived a stash-based approach as a safer option of getting drugs because a direct exchange of money for drugs could be avoided, and so the perceived risk of getting detained by the police was lower.

Buying hand-to-hand presented a constant risk of being arrested, since the seller’s place could be monitored by the police, or somebody could point police to other customers. Those who preferred buying hand-to-hand mitigated this risk by carefully selecting sellers, being cautious while buying, or outsourcing to somebody to get the drug in exchange for sharing the dose. Even buying hand-to-hand, people tried to avoid direct transaction, thus reproducing the benefits of stash-based approach:

I: Do you buy it [drug] from people?

R: Yes. From people, from stashes, whatever. Well, now all this is mostly done through stashes, and to do this in person… then that person has to really trust you… I can [buy hand-to-hand], but people try to be on the safe side. A after all, they try not to get it from hand-to-hand. So, they can just leave it somewhere and say: “Come out, I left it there.”

I: And because of what do they try to be on the safe side?

R: Well, because of what? Because of the police.

[Tetiana, female, 42 years old]

As a result of aligning preferences with circumstances, the everyday behaviors varied considerably between the participants.

“Naturalness” as an indicator of quality

PWID juxtaposed drugs in terms of degrees of ‘natural’ to rationalize their choice of drug type and form, and how and from whom to buy drugs.

The idea of “natural” vs. “chemical” product was salient during discussions of preferences for different types of drugs people use. For example, crystal methadone was considered a more potent drug than shirka, and it was cheaper for a buyer to use since lower doses were necessary to avoid withdrawal symptoms and the effects lasted longer. However, given a choice and in the absence of financial limitations, participants preferred shirka over crystal methadone because it was perceived to be less “chemical”. The ultimate standard of “natural” drug came from references to the product from the 1990s that people clandestinely prepared from poppy straw and also called shirka. Participants described with nostalgia the earlier practices of drug preparation (Rhodes & Bivol, 2012) and, as a continuation of such practices, some participants opted to prepare their primary drug from scratch using opioid-containing ingredients that could be bought in a pharmacy.

Participants further contrasted opioids and stimulants based on their immediate effects on mind and body and their long-term consequences on life and relationships. They linked these effects to the idea that stimulants were more “chemical” than opioids. Accordingly, participants believed that stimulant use led to quicker physical deterioration:

I thought that when these amphetamines appeared… Opiate users always lived up to 70 years old and well… Now drug users … dirty, stinky, man, they are like tramps…Few people keep themselves in… in good shape. Well, they are awful. Especially those people who use vint. They are stinky. It is a nightmare.

[Tetiana, female, 42 years old]

At the same time, study participants repeatedly associated drug quality with the perceived “naturalness” rather than the potency of the substance.

R: Sometimes I go through private residencies or in the country and see that poppy is growing there, then I will snatch it and make drugs out of it… [Or] if someone calls and says that there is a natural product, without chemicals, that is not some kind of shirka, but a natural product…

I: And this will be different from what you usually buy?

R: Of course!

I: In which way?

R: For the better.

[Oleksiy, male, 52 years old]

The preference towards stashes or hand-to-hand purchase was also linked to considerations of drug quality. However, the relationship between quality and mode of buying was not straightforward. Some participants were convinced that stashes allow more space to control the quality of the drug because buyers get to dilute and cook the final solution themselves (probably hinting at the potency). Buyers can also better control the contents of the final solution (implying that ready-made solutions could contain unknown and harmful substances). Other participants thought that hand-to-hand sales offer more “natural”, “homemade”, and “handmade” product. For example, Roksolana perceived that drugs prepared from stashes were of better quality compared to buying a ready-made solution.

R: Well, yeah, now we make [drugs]. It is just that we do not make at home, but we get stashes now… For example, two or three people chip in, get stashes, and make it at someone’s place.

I: And what does it mean that you chip in and get stashes?

R: Well, it is just that the stash has pressed concentrated opium [malyas]… You dilute it, make it at home…There are stashes that need 30 minutes to make them. They cost a little bit less, and you make the drug yourself, you know yourself what you use. It is cleaner, not as dirty as, say, they [sellers who offer ready-made solution] sell. I know what I’ve made, cooked, and used.

[Roksolana, female, 55 years old]

In contrast, Igor thought that some “chemicals” are sold through stashes, preferring to buy from a seller that he has known for a long time and whom he trusted:

R: Well, somehow… I do not know. Stashes appeared just recently, and my attitude to them… It is negative.

I: Why?

R: Well, because in stashes, they mostly sell some… chemicals. You do not know what it is. Like a substitute… for drugs.

I: And can you tell by your condition whether it is a drug or a substitute?

R: Well, I do not know. I try, like I say, to get [drug] from the same proven source all the time.

[Igor, male, 25 years old]

Participants often expressed mixed and contradicting ideas about potency and “naturalness” of the type, form, and way of buying the substance. Individual perceptions of which substances are “natural” and which delivery method provides “less chemical” product often represented opposing points of view. However, the type and form of the drug that was perceived as less “chemical” had the ultimate advantage among other options.

Trust and consumerism on the drug market

Choices for the type of drug, the form of the drug, and the way of buying were socially embedded, and contingent on the relationships with the sellers, drug use partners, and level of trust participants exhibited in these relationships.

The drug market structured the relationships between people who use drugs by either forcing them to pool money for the purchase or interact to exchange certain services for a part of the dose. As mentioned earlier, buying through stashes often involved pooling money together to afford the minimum required amount, which was usually followed by cooking and injecting together. Relationships between such partners implied trust, but the nature of this trust was mostly based on “mutual benefits” of engaging in a partnership.

The relationship between sellers and buyers of stashes was often framed as a consumerist transaction, a format that was relatively new to the Ukrainian context of the injection drug market. These interactions manifested in the way stash sellers marketed their product, a kind of customer support that stash sellers offered their customers in case of problems with finding a stash, and in the way, customers evaluated their experiences and their sellers.

Stash promotion activities included providing “bonus” stashes on the holidays, promotional messages to grow the client base and to enter the market and offering free samples. Buyers often were skeptical about free promotional stashes and messages. However, some mentioned that was how they found their source of stash. On the other hand, promotional messages indicated that there was always someone on the market who was offering the product buyers needed:

R: Crystal methadone, again, is purchased through stashes. You can buy everything that way, malyas also, - well, anything. They send a text message, like, “Torba and Co. are on board again.” I received such a message.

I: Like a commercial offer?

R: Well, they know the [phone] number of every drug user. I do not know how they do it, but my friends received the same message, word for word, I mean, “Torba and Co. are on board again.” That text message I received quite recently.

I: What did they inform you about that way?

R: Well, that they sell again, onboard again, meaning you can order drugs from them again.

I: Were there interruptions?

R: It did happen back in the day, the police pressured them, but I do not know what happened to them, but there was a time when they did not sell, and then they popped up again. I guess the previous [sellers] were put behind bars, and new people took their place.

[Denis, male, 30 years old]

In cases when the buyer could not find a stash, the seller often provided a different location, which was perceived as an effort to keep customers happy and loyal:

But when he tells you in detail the place, you come, and there is no pack of cigarettes [stash]… For something that we did not find, well… I will not say that constantly, but often he provided another place. Because he understood that he did not want to lose us as customers. Well, it is clear that we do not see him and do not know who he is. And how to catch and beat his face for such things - it’s not real. But he understands that, for example, today I did not find [the stash], tomorrow another addict did not find, the third, and this is how his business will be finished.

[Olga, female, 39 years old]

Buyers often described ‘good stash people’ as those who would choose stash locations that were reasonable and convenient for the buyer, send pictures instead of written directions, and provide clear explanations about the location of the stashes. It was these characteristics that were the reasons why buyers would keep buying from the same sellers. Quality and consistency in service were valued in addition to attributes of the substance itself, almost as if competition between sellers was based on customer service rather than characteristics of the drug itself.

Degree of control that participants perceived to have over the process of buying drugs also differed by a stash-based vs. hand-to-hand purchase. With stashes, there was a widespread perception that buyers lack control because money was transferred in advance, and the only way a person could contact the sellers was through the phone. Participants believed that buying through stashes meant taking on the additional risk of getting “stiffed” by a seller. Even though participants rarely mentioned situations in which they did not get the product after transferring the money, they were almost unanimous in considering such risk:

R: The feeling when I deposit money and… That also includes… the fear of being stiffed (laughs).

I: Who can stiff you?

R: Well, things happen. They will either not place that stash at all, or someone… they place it, and someone finds it… You arrive at the spot, and it is not there. It is actually a big-time wipeout… You sort of had the money, and you seemed to have had those prospects, and here it has all gone… In that case my hands and legs… and my head stop operating. That is a total loss of strength. You understand that what is coming next is far too bad… Total dead end.

I: Does that happen often?

R: Oh, no. It happens very rarely. But it is better never to experience such situations.

[Pavlo, male, 40 years old]

Regardless of whether the drug is bought through stashes or hand-to-hand, trust between buyer and seller was the foundational element of all transactions. In the case of stashes, trust was necessary for buying drugs for the first time from an unknown seller, and trust was something that retained clients in the long run, thus creating and maintaining long-term relationships between sellers and buyers who have never seen each other.

Similar to stashes, finding a trusted hand-to-hand seller took time but also required more social capital in the form of personal introductions and vouching. Therefore, the bar for trust was higher for hand-to-hand purchase because of the risks related to the direct transaction. The nature of trust was also different and would often involve some sort of personal relationship.

The intricacies of social and technical organization of drug distribution resulted in hierarchies among drug market participants that were exploited by sellers and buyers and led to the formation of ad hoc relationships. For example, the drug market described by participants created “intermediary” jobs in response to the uncertainties of transactions. These intermediaries were designed to connect buyers and sellers, perform the most dangerous tasks such as picking up stashes or buying through hand-to-hand, and cooking drugs or exploit personal social standing. Some participants were particularly proud of direct contact with the seller because it heightened their social status by enabling them to provide intermediary services. One example of cooperation created to fit the drug market structure was when a group of people had one representative who bought drugs for everyone through personal connections at a lower price than each of them would buy separately. This person would then cook for everyone and receive payment in drugs:

No, I come to his place. Just two people go to him, three persons in total. So, we’ve organized such a small syndicate. I’m a financier. Once a week, I give this guy 500 rubles [UAH]. He starts working with these 500 rubles [UAH], I mean, he buys a cube and three points [1.3 milliliters]. They usually sell a cube, and he somewhere found a cube and three points of malyas. This cube and three points of malyas are easily diluted into 12 cubes [12 milliliters] of very good quality [drug]… He gives me, and that’s it. I take one and a half [1.5 milliliters] and a half cube I inject. I leave him a 100 hryvnias and leave. That’s it, until the next morning. Then I go to work.

[Stepan, male, 53 years old]

Similarly, trust toward intermediaries was a prerequisite, and intermediaries often were chosen based on their availability as well as on their trustworthiness. Often people who performed these ‘intermediary’ jobs also would become part of the group who inject together, thus forming a new social entity that is not bonded by friendship but by the market. Participants described that in different moments of their life, they performed such jobs because either their social position gave them leverage or they needed the drug but did not have money to get it. Alternatively, people with an advantageous social position were gatekeepers to getting drugs within a social group.

Discussion

Descriptions of the drug markets have been criticized for being more concerned with eliminating the “problem” (whether it is drug use, infectious disease, or overdose) rather than understanding how drug markets change, structure everyday choices and influence relationships (Curtis & Wendel, 2000). In response to this critique, the present paper explored the current retail level of the injection drug market in Ukraine focusing on types and forms of drugs available, ways of buying drugs, and relationships formed and maintained within the market. Our study provides an update and extension of studies on the context of injection drug use and retail drug market in Ukraine, specifically, the technical and social organization of injection drug retail as it was experienced and perceived by PWID in Dnipro, Ukraine. The multipart contingencies of retail drug market described in this paper have many implications for reduction and minimization of the negative health and social costs of drug use and abuse.

The retail level of drug markets is complicated by multiple characteristics that could be used to describe it: type of drugs, location of sales, cultural influences and specifics of social relationships within it (Potter, 2009). We argue that the social and technical organization of the retail drug market in Ukraine illustrates the strategies that developed in response to the fundamental problem of drug distribution: uncertainty (Moeller, 2018). Uncertainty is a central feature of illicit transactions, and the diversification and digitalization of the retail drug market in Ukraine have contributed uncertainties for buyers related to the quality of drugs, ways of getting drugs, and other actors.

The concept of “transaction cost” helps explain how actors manage uncertainties that occur on the retail level of the injection drug market in Ukraine (Belackova, Maalsté, Zabransky, & Grund, 2015). Transaction cost theory explores the limitations in making decisions within complex and uncertain environments characterized by information asymmetry and bounded rationality, such as drug markets (Moeller, 2018; Williamson, 1981). In our data, transaction costs included the cost of finding reliable and suitable sellers, the cost of reducing the uncertainty of sending money and picking up the stash under the threat of being stiffed or caught by the police, and uncertainty about the product itself. Establishing trusted relationships within the market is one strategy to reduce transaction cost and risks (Potter, 2009). Moeller (2018) suggested that market actors learn to trust each other as a strategy to reduce uncertainties and make transactions possible. Potter (2009) also suggested that friendship-like relationships between the seller and the buyer decrease the perceived concerns about the transaction. Participants in our study reduced uncertainty and transaction cost by trusting unknown, new sellers of stashes, building friendly relationships with the hand-to-hand sellers and involving intermediaries for risk outsourcing.

Another strategy to reduce transaction cost is to leave the market or minimize contact with it. In our data, an excellent example of minimizing contact with the market is when a group of people found a trusted person who organized the whole process: buying, cooking and splitting in exchange for money or a part of the dose. Arguably, people who continue buying through hand-to-hand also reduce their transaction costs by interacting only with those whom they see and know. Additionally, the “do-it-yourself” phenomenon widespread in the post-Soviet countries due to the scarcity of many consumer goods (Belackova, et al., 2015) is also an example of how people on the drug market in Ukraine reduce their transaction cost by learning how to cook the solution themselves.

Finally, having convenient and simple heuristics about product quality may help reduce the transaction cost when little to no information about the product is available. For example, in our data, the perceptions of a drug as “natural”, or perceptions of a seller who provided more “natural” product, offered participants a heuristic to evaluate and classify the product in the absence of other objective market information about the drug they were buying.

The described system of drug distribution could be contrasted with the one described for the late 1990s – early 2000s and often referred to as an “open” drug market, in which people needed to know the location of sales and gain the trust of the sellers for an in-person transaction to occur. During that period a majority of injection drug retail sales would happen at a meeting point, for example, at an open land between state and private housing, and seller would deliver drugs in an already pre-filled syringe in liquid form ready to inject (Booth, 2013; Booth, et al., 2003; Rhodes, 2002). Previous studies reported that homemade opioids were the main drug type used by PWID in Ukraine (Booth, et al., 2003; Dumchev, et al., 2009; Rhodes, et al., 1999) and buying a ready-to-use drug was the most common way of getting the drug (Barska & Sazonova, 2016). In our study, the relative isolation of many buyers from each other, limited information flow between buyers about the product quality, and amount of time and energy buyers invested in finding a permanent seller could be indicative of more closed market (Curtis & Wendel, 2000). Therefore, reliance on symbolic naturalness of the product could be considered a heuristic for operating in the more closed drug market.

Our findings suggest that despite opioids remaining the most prevalent drug type, technologies of its preparation and the selection of opioids have diversified with new opioids available for consumptions in the form of ready-to-use (drug-solution) and semi-finished (malyas, crystal methadone) products or ingredients that require preparation. However, such diversification came with a reduction of control over which substances are present in the end-product. Further, the changes that occurred in the modus operandi of buying drugs are among the most intriguing findings from our data. Our study participants still reported buying drugs from sellers who cook drugs for small groups and from street-sellers but also implied that such retail strategies are remnants of the past. The stash-based mode of drug distribution became popular and even dominant according to some participants, enabled by developments in banking and mobile technology that made operations more efficient. Thus, our data further highlight the significance of innovations in the equipment and technology used in retail drug distribution (Curtis & Wendel, 2000). As was previously demonstrated with the arrival of mobile phones, technological advances enable major transformations in the organization of drug retailing, particularly for the small-sized retailing entities (Bouchard, 2007; Curtis & Wendel, 2000; Paoli, 2002). In our research, this new way of buying exists alongside the old ways, illustrating different retail strategies coming into contact. Potentially, as was demonstrated for the marijuana market on the lower East Side of New York City (Curtis & Wendel, 2000), the benefits of technological transformation that enabled stash-based mode of retail may largely eliminate hand-to-hand approach of injection drug retailing. The transition from open to more closed injection drug markets at the turn of the centuries have been described for neighboring Russia, though at that time authors were more focused on the role of police repression and extortion, weather conditions and technologies of preparation as driving forces of such change (Paoli, 2002). The hypothesized shift from open to closed drug market in Ukraine and its implications for the people should be investigated further.

Stakeholders could utilize the information about multifaceted behaviors that result from the intersection of different relationships and technical factors that dynamically exist in the drug market by incorporating it into policy and service development. First, harm reduction programs in Ukraine (APH, 2018) could use these data to develop more efficient and client-oriented strategies to provide services to their target group based on an understanding of why, what, when and from whom people buy drugs.

Second, it is apparent that understanding social networks and leveraging this knowledge to deliver behavior change intervention could be a more efficient way compared to individually-based interventions. For example, substantial evidence has been gathered to indicate that characteristics of social networks such as size, range, density, boundedness, proximity, homogeneity, reachability, and centrality could be utilized to improve the effectiveness and efficiency of the distribution of knowledge and skills and identification of those most at risk (Kerensky & Walley, 2017; Latkin, Edwards, Davey-Rothwell, Yang, & Tobin, 2018; Latkin, Hua, & Tobin, 2004; Latkin & Knowlton, 2015). The efficiency of such approach has also been demonstrated for finding undiagnosed HIV-positive people in Ukraine and changing HIV risk behaviors (Booth, Lehman, Dvoryak, Brewster, & Sinitsyna, 2009; Booth, et al., 2011; Smyrnov, et al., 2018).

Third, behavioral strategies offered by NGOs to reduce harms associated with drug use may incorporate knowledge about how the drug market and relationships within it shape drug use behaviors. For example, the decision to inject with other people often was not defined by preferences but by the necessity to pull money or to inject in a seller’s place (Booth, et al., 2013). On the other hand, preferences towards certain drugs, market forces in the form of drug availability and cost should be understood to assure that harm reduction services can respond to a dynamic drug market, for example in case of an influx of high potency drugs. Therefore, continuous monitoring of the local retail drug market characteristics should be a part of the routine activities of service providers and policymakers. These characteristics may include the drugs available, the modality of sales (currently drugs are mainly sold either through stashes or hand-to-hand), relationships between the sellers (whether they resemble customer-seller interactions), the buyers and the intermediaries (based on risk outsourcing, social capital, and trust), and how they interact with each other.

This study has several limitations. First, our data describe the retail drug market perspective of the buyers, which may differ from the perspective of sellers. However, for the service providers who serve PWID, such perspective is prioritized, and the perspective of the sellers remains a potential and exciting avenue for future research. Second, conclusions and implications from our study should be transferred to other settings within Ukraine cautiously. However, based on our fieldwork in other cities and the bio-behavioral survey (Barska & Sazonova, 2016), co-existence of stash-based and hand-to-hand sales is a phenomenon spread throughout the country. Third, we did not explore the sociodemographic differences in narratives about the drug market and relationships within it and by the drug of preference. These were outside the scope of this paper and require future investigation. Finally, these results describe the drug market and relationships within it only for PWID, while people who use non-injecting drugs may experience circumstances of drug purchase differently.

Understanding people who inject drugs through exploring how drug markets structure the choices of people who buy drugs, how individuals respond to the circumstances and how relationships are formed within the current drug market is one of the pillars of developing useful and attractive services for PWID. For example, given the limited information about the product on the market agencies may pilot and implement drug checking services that will help buyers to make better informed choices. Our results indicate that the technical and social organization of the retail drug market in Ukraine stimulates the formation of relationships and impacts the choices of what, how, and when to inject beyond individual preferences. The way sellers and buyers initiated and maintained relationships indicated that mobile and banking technology penetrated retail injection drug market in Ukraine. The management of uncertainties through the lens of “transaction cost” could explain how drugs and sellers are chosen, why some buyers trust unknown sellers, use the intermediaries to outsource risky operations, and form groups to procure and inject drugs together. Within the described drug market despite important structural forces, personal preferences also shaped everyday behaviors and social circles, therefore these data could be used for the development of individual, group-based and structural interventions. Altogether, these results help further the study of local retail drug markets and illustrate the social embeddedness of its operations.

Highlights:

• Opioids available at retail-level are diverse in type and preparation technologies

• Buyers use perceived ‘naturalness’ of the drug to reduce selection uncertainty

• Banking and mobile technologies enabled new retail strategies for injection drugs