Changes in patterns of injecting drug use in Hungary: a shift to synthetic cathinones

Research articleDrug Testing

and Analysis

Received: 5 September 2013 Revised: 26 January 2014 Accepted: 26 January 2014 Published online in Wiley Online Library

(www.drugtestinganalysis.com) DOI 10.1002/dta.1625

Changes in patterns of injecting drug use inHungary: a shift to synthetic cathinonesAnna Péterfi,a* Anna Tarján,a Gergely Csaba Horváth,a Tamás Csesztregib

and Adrienn Nyírádya

The spread of synthetic cathinone injecting is a new phenomenon observed in recent years in Hungary. Until 2010, when thefirst anecdotal reports on cathinone injecting appeared, injecting was associated with the use of heroin and amphetamine. Inthis paper we review available evidence of the changes in the drug market and a concurrent shift in patterns of injecting druguse that have been taking place in Hungary since 2010. Remarkable changes have been observed in police seizures data since2010. While new psychoactive substances have appeared, the availability of heroin has dropped significantly. A qualitativestudy in 2011 revealed that these market changes correlate with changes in patterns of injecting drug use: decreasing heroinuse and the appearance of mephedrone injecting were reported by treatment and needle and syringe programme (NSP)personnel. These changes are detectable in other routine epidemiological data collection systems in the following years aswell (i.e. treatment, drug-related deaths, NSP clientele). Heroin-related treatment demand dropped, as did heroin-relatedmortality. Parallel to this, a growing number of clients appeared in treatment and in NSPs who were primarily injectingcathinones. The shift to cathinones can be observed in amphetamine and heroin injectors as well. Monitoring changes inpatterns of injecting drug use are especially important because of the vulnerability of this drug-user population and theconsequences of this high-risk route of drug administration. The realignment observed in Hungary is to be further investigatedwith regard to its determinants, changes in risk behaviour, and in treatment needs. Copyright © 2014 John Wiley & Sons, Ltd.

Keywords: injecting drugs use; patterns of use; synthetic cathinones; heroin shortage

* Correspondence to: Anna Péterfi, 7 Ponty utca, 2085 Pilisvörösvár, Hungary.E-mail: [email protected]

a Hungarian National Focal Point (REITOX), National Centre for Epidemiology, 2-6Albert Flórián út,1097, Budapest, Hungary

b Hungarian Institute for Forensic Sciences, 9 Mosonyi utca,1087, Budapest, Hungary

1

Introduction

Data on injecting drug use in Europe have shown a long-termdecline. This route of drug administration is generally associatedwith the use of heroin, although in a few countries the injectionof amphetamines is the major problem.[1] Considering the historyof drug use in Hungary in the 1970s and 1980s, injecting was asporadic phenomenon. This period was characterized by theuse of medical opiates, then later by the use of poppy tea andother home-made poppy products (Lénárd, unpublished; Bajzáthet al., unpublished). Injecting drug use became more widespreadin the 1990s partly induced by changes in the drug marketfollowing the political change in 1989. In this decade, heroinreplaced the homemade poppy products, first in the capital,and later in rural areas, and became the main drug injected bythe end of the decade.[2]

Gyarmathy et al. observed injecting amphetamine use at the turnof the 1990s and 2000s in Budapest, especially among non-treatedpeople who inject drugs (PWID).[3] By the end of the decade it hadspread, characterizing around one-third of PWID in the country.[4]

Regarding the size of the problem of injecting drug use in thecountry, there have been two studies carried out so far.[4,5]

According to the latest study,[4] the total number of injectingdrug users was estimated to be 5699 in the reference period of2008 and 2009. The prevalence rate was 0.82/1000 persons inthe15–64-year-old population.

The appearance of new psychoactive substances has beenmonitored in Hungary since 2004. In the period between 2004and 2008, the emergence of these substances was not a signifi-cant feature of the Hungarian drug market. The first syntheticcathinone, mephedrone (4-methylmethcathinone) was identified

Drug Test. Analysis (2014)

in 2009 from a police seizure.[4] At this time there was very little in-formation on the patterns of mephedrone use. During the summerof 2010, over the course of a three-month period, it became themost prevalent synthetic drug in the market according to seizuresdata.[6] In the same year, anecdotal information from harm reduc-tion and treatment professionals suggested the spread ofmephedrone use as well as the appearance of its injecting use.

As standardized data collection systems (i.e. treatmentdemand indicator, drug-related deaths indicator, and NSP data)with national coverage were not sophisticated enough to collectinformation on emerging substances, the authors conducted aqualitative study in 2011 among harm reduction and treatmentprofessionals to establish an overview on the emerging phenom-ena directly from frontline workers.

In the following years, data collection systems were furtherdeveloped so as to be able to provide information on newsubstances. Data from routine data collection systems weresupplemented by qualitative studies to help interpretation.

A number of small-scale studies had consistently suggested thatsynthetic cathinone injecting has appeared in Hungary[2,7,8];however, no research paper has given a comprehensive picture ofthe changes from a national perspective. The aim of this paper isto fill this gap and to provide an overview of cathinone injecting

Copyright © 2014 John Wiley & Sons, Ltd.

A. Péterfi et al.

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by reviewing available evidence (primarily national data) and bypresenting the results of our qualitative study on changes in thedrug market and a concurrent shift of patterns of injecting druguse that have been taking place since in Hungary 2010.

Data sources and methods

In this paper we present two types of data: analytically confirmedand non-confirmed data. The distinction is important from theaspect of limitations and data interpretation. Data obtained onseizures and drug-related direct deaths are confirmed by forensicanalyses, while data obtained on treated drug users and onclients of NSPs are self-reported, analytically non-confirmed data.Trends observed in the different sources are interpreted in aparallel fashion in this paper to overcome the limitations of thedifferent data sources.Seizures data, drug-related deaths data, and data on NSP

clientele are presented each year in the Reitox national drugreports of Hungary. Aggregate data were obtained from thesources of these reports and are presented in the paper.New analysis was carried out to present trends of PWID clients

starting treatment based on treatment demand indicator (TDI)data.[9]

Seizures data

Seizures data are presented on the basis of analytical results fromthe Hungarian Institute for Forensic Sciences (HIFS). The labora-tory network of the HIFS is responsible for the forensic analysisof seized illicit drugs and related substances. Both small (streetquantity) and large quantity seizures are included in the statistics.Seizures data on drugs associated with injecting are included forthe period 2008–2012.Specific statistics on samples of seized injecting equipment

(needles, syringes, filters, and spoons) are also provided by theHIFS for the period 2009–2012. Analyses of injecting equipmentare carried out in a limited proportion of such cases (2–5%) dueto the high risk of accidental infections. The HIFS laboratories al-ways carry out the analysis of such objects (therefore all of thesecases are included in the statistics) when no substance is confis-cated next to the seized injecting equipment. These cases giveapproximately 70% of the results shown in these statistics. Theremaining 30% is a random selection of cases when bothinjecting equipment and substance had been confiscated bythe police. In at least 95% of the cases, a single object is exam-ined per seizure.

The method of analysis

Contaminated surfaces of seized items are treated with solventsand the solutions are analyzed directly by gas chromatography-mass spectroscopy (GC-MS). During the period 2009–2012,injecting equipment was analyzed in 132–188 instances per yearin Hungary.

Drug-related deaths data (DRD data)

Data on direct drug-related deaths (overdoses) are collected inthe system of the National Centre for Addiction in partnershipwith the Hungarian National Focal Point (HNFP) and the Depart-ment of Forensic Medicine at Semmelweis University. For thepurpose of annual statistics, cases are identified and further infor-mation collected from forensic medical experts responsible for

wileyonlinelibrary.com/journal/dta Copyright © 20

the given cases. Forensic examinations of drug-related deaths(DRDs) are carried out by the pathologists supported by GC-MStoxicological analyses of the biological samples for illicitsubstances including cathinones. Forensic examinations, includ-ing toxicological analyses, are compulsory in all unnatural cases.In rare cases when causes of death are obvious (e.g. trauma)detailed toxicological analyses may not be carried out duringautopsies, thus some indirect cases may remain unreported.Case-based data are compiled on an annual basis in the specialmortality register (fully in line with the European MonitoringCenter for Drugs and Drug Addiction (EMCDDA) definition[10])and controlled against the general mortality register at the na-tional level. In this paper, we review all direct DRD cases between2009 and 2012, excluding indirect deaths. Cases are divided intothree categories: (1) opiates cases excluding methadone-onlycases that include all cases where opiate metabolites weredetected alone or in combination with any other substances; (2)methadone-only cases; and (3) other, non-opiates cases, whereonly substances and metabolites of other drugs could bedetected. As a result of the technical problems arising from thetoxicological identification of new substances and due to the in-complete knowledge of the health consequences, death cases in-volving new psychoactive substances (among them cathinones)are presumed to be underreported in DRD data.

Treatment data (TDI data)

Data on treated drug users are available from the national TDIdata collection,[11] operated by the National Centre for Addictionsin partnership with HNFP, on clients starting drug treatmentprogrammes (for first time in their lives or repeatedly). All special-ized outpatient and inpatient treatment units and social servicesproviding drug treatment are obliged to report to the system. In2012, 81 units reported new clients. The coverage of the data col-lection was approximately 80–90% with respect to all cases com-plying with definitions.[11] Information on patterns of use isreported for the reference period of 30 days prior to enteringtreatment. Data are self-reported by clients. Case-based dataare compiled on an annual basis, and controlled for doublecounting at national level. From this system, data were extractedon clients who reported injecting as the main route of adminis-tration of their primary drug between 2009 and 2012. Data hasbeen cleaned and cases reoccurring more than once in the givenyear were excluded. Cases presented include ‘heroin’, ‘metha-done’, ‘other opiate’, ‘amphetamine’, ‘cocaine’, ‘other stimulant’and ‘other drug’ injectors. Percentages were calculated on thebasis of this selection. The analysis of the data was carried usingthe SPPS programme package.[12] Since the variable ‘primarydrug’ does not include a specific category for cathinones, thesecases had to be tracked separately; they were identified byconsulting treatment service providers.

NSP clientele data

Data on NSP clients operating in Hungary are collected by theHNFP. Data are reported on a voluntary basis. In 2012, 25 of the28 (fixed and/or mobile) NSP centres operating in the countryreported data on their clients. The coverage of the data collectionwas approximately 70% with respect to all NSP clients. Datapresented in this paper refer to the period between 2009 and2012. In this period, the variable ‘primary injected substance’was modified. Between 2009 and 2010, data were collected in

14 John Wiley & Sons, Ltd. Drug Test. Analysis (2014)

Changes in patterns of injecting drug use in Hungary: a shift to synthetic cathinones

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and Analysis

four categories: ‘heroin’, ‘amphetamine’, ‘cocaine’, and ‘other’.Starting in 2011, due to the presumed changes in the main drugsinjected, the category ‘other’ had to be specified. Data on theprimary injected substance are self-reported by clients to serviceproviders who report their aggregate data to the NFP annually.The primary drug is recorded on registration in the programme,but due to changes in past years, it is annually updated by mostof the service providers. Substances were often reported usingtheir street names. The most frequent ones were known to bederived from mephedrone (‘mefedron’, ‘kati’), MDPV (‘MP’,‘MP3’, ‘MP4’), 4-MEC (‘formek’), and pentedrone (‘penta’,‘pentakristály’, ‘kristály’) while others that could not be identified(e.g. ‘capsule’, ‘designer drug’) or appeared with a very lowfrequency (e.g. methylone) were categorized as ‘other drugs’.Some of the latter cases presumably belong to the group ofcathinones; however, it was decided to handle them separately.Data are controlled for double counting at service provider levelbut not at national level.

The qualitative study among treatment and harm reductionprofessionals

To explore the new phenomena in patterns of drug use, theauthors carried out a qualitative study among frontline workersof outpatient and inpatient drug treatment services and harmreduction services. The study was commissioned and supportedby the HNFP. Questionnaires were sent to the biggest inpatientand outpatient drug treatment units (31) in the country and tothe biggest NSPs (12) in May 2011. Units were chosen on thebasis of TDI data and NSP client data to represent the units withthe highest turnover in the country and also to cover at least oneunit in each of the seven geographical regions of the country.Questionnaires were e-mailed and filled in by the head of theunits or the programme leaders of the organization. The ques-tionnaire included six open questions about the new phenome-non experienced in 2010 inviting them to report on any kind ofchanges observed in their clientele. All together 20 treatmentunits and 9 NSPs participated in the study voluntarily,representing all regions of the country.

Results and discussion

Anecdotal information on injecting cathinone use appeared inthe second half of 2010. Our qualitative study was the firstattempt to capture reliable information on this phenomenon.

Figure 1. Number of seizures of injectable substances between 2008 and 2* cocaine and methamphetamine

Drug Test. Analysis (2014) Copyright © 2014 John Wiley

NSPs participating in the study reported the spread ofmephedrone (in some cases described as bath salts) injectingfrom the second half of 2010 among their clients. The appear-ance of new, younger injectors and transitions from othersubstances were also observed.

The second important finding confirmed by services was asharp decrease in the number of heroin-injecting clients. Theseclients did not disappear from the programmes but changed toother substances, among others to mephedrone.

First of all, easy accessibility and the low price of the substancewere mentioned as causes for changing drugs. The former legalstatus of the drug and the perception of low risk associated withit appeared as a further reason, together with the lack of detect-ability by rapid tests and its more intensive effect compared topreviously injected substances. On the basis of professionals’perceptions, the accessibility and purity of heroin deterioratedsignificantly in the middle of 2010, and the low active substancecontent of amphetamines also acted in favour of switching tonew drugs. Mephedrone was reported to be injected morefrequently than heroin or amphetamine, which increased thedemand for syringes.

This qualitative study was the first research initiative to collectinformation on the changes in injecting patterns with a nationalperspective. In the next part of the paper, these observationsby the professionals consulted are also examined in quantitativedata (derived from routine data collections) with the ability todirectly or indirectly identify trends in drug supply and demandin Hungary.

Changes in the market

Two parallel phenomena could be observed in past years’seizures data: a reduction in heroin-related cases and an increas-ing number of cathinone seizures. The identification of the firstsynthetic cathinone, mephedrone was reported to the nationalEarly Warning System[13] in October 2009. From 2009, there wasa sharp increase in the number of cathinone seizures rising fromthe two cases reported in 2009 to 874 seizures in 2012(Figure 1). In 2011 and 2012, the number of seizures associ-ated with cathinones exceeded the number of seizures associatedwith amphetamine. In 2010, mephedrone; in 2011, 4-MEC(4-methylethcathinone) and MDPV (3,4-Methylenedioxypyrovalerone);while in 2012 pentedrone (β-ethyl-methcathinone) dominatedcathinone-related seizures.[14–16] The proportion of cathinoneseizures with a maximum quantity of 100 grams (considered tobe the dealer and end-user level) represented approximately 95%of all cathinone powder seizures between 2010 and 2012. Seizures

012. Source: Hungarian Institute for Forensic Sciences

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data indicates the increasing availability of cathinones both atstreet level and at wholesale level. The widening availability ofcathinones is also suggested by snapshot studies of the onlinetrade in new psychoactive substances in 2011 and 2012[14,15] andby two further studies conducted amongdrug users.[15,17] The avail-ability of cathinones was partly determined by the legal status ofthese substances as until 2011 none of these substances weresubject to control measures in Hungary. Mephedrone has beenscheduled as an illicit drug with effect from January 2011 followedby MDPV and 4-MEC in January 2012. New legislation aiming toreduce the availability of new psychoactive substances wasadopted with effect from May 2012 sanctioning supply-relatedactivities with these substances. In this special schedule (scheduleC of Government Decree 66/2012) cathinones were added usinga generic definition as a result of which pentedrone and othercathinones were ‘automatically’ covered by the new legislation.The other remarkable phenomenon observed in seizures data

is the significant decrease of heroin cases both in proportion tototal seizures and in the absolute number of seizures associatedwith the substance. The figures clearly indicate changes in thestreet-level availability of heroin as the proportion of heroinseizures with a maximum quantity of 100 grams (considered asa dealer and end-user level) represented approximately 90% ofall heroin seizures in the observed period.It is not solely Hungary where a reduction in the availability of

heroin has been observed. According to Griffith et al.,[18] therewere a number of countries in Europe who experienced a ‘shock’in heroin availability around 2010. They found that the commoncharacteristic of these countries is that in all of them heroin istrafficked through Turkey. As was confirmed by the EMCDDA,the UNODC, and Hungarian sources as well, the Balkan traffickingroute traversing the country seems to have been losing its signifi-cance in recent years.[15,19,20] A remarkable drop in the number ofheroin-related seizures from 2010 to 2011 has been reported bySlovakia (77%), Hungary (70%), Romania (67%), Croatia (54%)Bulgaria (46%), and by the Czech Republic (44%) to the EMCDDA.[21]

Based on national seizures data it can be inferred that theheroin market in Hungary has not yet stabilized.

Changes in the patterns of use

Changes in patterns of injecting drug use can be observed bothin data that directly or indirectly reflect patterns of drug use.Injecting drug users form a population of users with a high la-tency. Tracking changes in their distribution and their patternsof drug use is especially difficult. In Hungary, three sources areavailable which have the potential to indicate national trends inthis user population: TDI data, NSP client data, and DRD data. In

Figure 2. Number of direct drug-related deaths by drug type between 20National Focal Point


the following section we try to identify parallel trends in thesedata sources and draw conclusions regarding trends in PWID.

The consequences of the enduring decline in the availability ofheroin are detectable in all of the three data sources weexamined. Changes in the consequences of use, such as changesobserved in treatment demand and direct DRD cases indicatechanges in drug use in themselves.

Even when the case numbers are low, the reduction is strikingin cases of death directly related to opiates (Figure 2). The num-ber of detected fatal intoxications caused by ‘opiates’ (excluding‘methadone-only’ cases) shows a 3.5-fold decrease from 2009 (28cases) to 2012 (8 cases). Parallel to this there has been a 5-fold in-crease in the number of fatal intoxications due to ‘methadone-only’ and ‘other drugs’ in total (2009: 3 cases; 2012: 16 cases).These data only confirm the fall in heroin use among PWID, anddo not imply that they turned to cathinones injecting.

Changes in patterns of injecting drug use and related treat-ment demand is also detectable in TDI data (Figure 3). The pro-portion of PWID starting treatment with heroin as their primarydrug shows a decreasing trend since 2010. While, between2008 and 2010 these clients represented the majority of theinjecting drug users new to treatment, in 2011 and 2012 theirproportion dropped markedly. At the same time the proportionof ‘amphetamine’, ‘other stimulant’ and ‘other (unclassifiable)drug’ injectors increased. The proportion of ‘other stimulant’and ‘other drug’ injector clients increased in total from 1%(2008 and 2009) to 21% by 2012. Although it is hard to determinethe exact proportion of synthetic cathinone injectors due to theuse of these wider categories, based on consultations with ser-vice providers it is assumed that the vast majority of clientsreported as ‘other stimulant’ and ‘other (unclassifiable) drug’ in-jectors were cathinone users.

Data on NSP clients provide an important source of informa-tion on PWID in Hungary partly covering out-of-treatment groupsof this population, invisible to the treatment data collectionsystem. While in 2009 the majority of clients reported the primaryinjection of heroin, from 2010 the picture started to change(Figure 4). In the observed four-year period, the proportion ofheroin injectors dropped from 56% to 17% while the ‘other drug’category increased from 4% to 43%, representing the biggestgroup of NSP clients by 2012. In the same period the proportionof amphetamine and cocaine injectors remained stable.

NSP data provide a more in-depth insight in the substancesreported as ‘other drugs’ for 2011–2012 (Figure 5). In these years‘other drug’ had to be specified based on clients’ reports. In 2011,the main ‘other drug’ reported was MDPV, while mephedroneand 4-MEC injecting was also detectable among clients. Only afew clients reported the primary injection of pentedrone in

09 and 2012 (people). Source: National Centre for Addictions, Hungarian


Figure 4. Breakdown of NSP clients by primary substance injected between 2009 and 2012 (%). Source: Hungarian National Focal Point

Figure 5. Breakdown of NSP clients injecting ‘other’ substances by thename of substance self-reported by client between 2009 and 2012(people). Source: Hungarian National Focal Point

Figure 3. Breakdown of PWID starting treatment by primary drug between 2008 and 2012 (%). Source of data: National Centre for Addictions,Hungarian National Focal Point


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2011 which had become the predominant substance injected byclients reporting ‘other drug’ injection in 2012. Besidepentedrone, MDPV, mephedrone, and 4-MEC still had a signifi-cant share in this group. Summarizing data from 2011 and2012, in 2011 a total of 501 clients named a substance associatedwith cathinones making up 22% of all reported NSP clients. In2012, the number of clients who reported injecting syntheticcathinones increased to 649, which is 34% of all NSP clientsreported that year.


The HIFS’s specific statistics on samples obtained from seizedinjecting equipment (needle, syringe, filter, spoon) provide ana-lytically confirmed data on the substances injected. Accordingto the sample of 133–188 cases per year (Figure 6), heroin wasthe main drug injected in 2009 making up 62% of the analyzedcases. The proportion of heroin samples decreased to 4% by2012. The proportion of amphetamine also shows a decreasingtrend in the four years examined (2009: 26%; 2012: 16%). Parallelto this, new, emerging substances such as mephedrone, MDPV,4-MEC, pentedrone, and other substances (among them othercathinones) and combinations (among them combinations ofcathinones and ’classical substances’) seem to have replaced her-oin and amphetamine. Looking at the proportion ofmephedrone, MPDV, 4-MEC, and pentedrone in total it can be in-ferred that these substances first appeared in 2010 with a nota-ble 36% share of all examined cases and since then anincreasing trend can be observed in their presence on injectingequipment (2011: 40%; 2012: 48%).

Seizures data show a remarkable and enduring reduction ofheroin availability in the Hungarian market that has beenfollowed by a reduction in the number of fatal overdoses associatedwith opiates, a reduction in heroin related treatment demand inPWID and a remarkable fall in the proportion of heroin injectingclients in national NSP data.

It is clear from the data presented here that heroin availabilityhas been significantly reduced and has lost its dominance amongPWID. However, the majority of these users do not abandoninjecting but change to other substances as confirmed by


Figure 6. Distribution of active substances detected on injecting equipment between 2009 and 2012 (%). Source: Hungarian Institute for ForensicSciences

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treatment and harm reduction professionals consulted in thequalitative study. The restructuring of NSPs clientele by the typeof the substance injected also supports the hypothesis of drugchange, as no drastic exchange of clients has been reported bythe services and programmes.When examining clients starting treatment, among the 74

cathinone users (between 2009 and 2012) who reported to havebeen treated before, 39 people could be identified in the TDIdataset as reoccurring cases from another year (recorded since2005). Among them 19 were treated previously as injecting drugusers of whom 6 injected heroin, 5 amphetamine, and 2 other‘classical’ substances. A further 6 clients reported the injectionof cathinones in their previous treatment episode. Although thenumbers are low, the history of the tracked clients also confirmsthat beside the appearance of new injectors, heroin and amphet-amine injectors also changed to cathinones and developed treat-ment demand due to these substances.This is also supported by further studies carried out in the

PWID population in Hungary.[2,7,8]

Information on the links between the heroin shortage and thespread of synthetic cathinones among PWID is still not sufficientto positively determine which factor could have triggered theother one. The factors mentioned by participants of our qualita-tive study that could have influenced this change in the patternsof use were: (1) the legal status and the non-detectability of thesesubstances; (2) decreasing purity and availability of heroin andamphetamine; (3) the intensive effect of cathinones; and (4) pricethat is less than one-third of the street price of heroin accordingto the price most frequently reported in the survey conducted byHNFP among drug users.[15]

Are cathinones replacing heroin or is it merely a temporarysubstitution similar to the one observed in case of the Australianheroin shortage in 2001?[22–24] Whether any of these scenarioscan be later proved by further investigation, the change froman opiate-type depressant drug to a substance with stimulantproperties requires further explanation.In all countries struggling with the emergence of new psycho-

active substances, the palette of compounds available changesrapidly to circumvent changes in legislation.[25] This is also appar-ent in our analysis of the Hungarian seizures data, and in thespecial statistics on the active substance content of seizedinjecting equipment. The regular alterations in the marketencumber the identification of substances injected and themonitoring of changes in patterns of use.When comparing substances reported by NSP clients and

substances identified in injecting equipment, it becomes apparentthat street names do not necessarily refer to the same substances.


The lack of knowledge of the substance and therefore its purity,dosing, effects, health consequences, etc. increases the risks relatedto its use. Further risks linked to cathinone use derive from usersinjecting more frequently, a phenomenon reported by treatmentand harm reduction personnel consulted in the scope of thepresented qualitative study.

Detection of new trends is challenging from existing routinedata collection systems. Our analysis suggests that triangulationof data and methods[26] are possible tools to overcome thesechallenges and to improve the reliability of the observations.

From a European perspective, cathinone injecting has beenobserved as a sporadic or geographically concentrated phenom-enon in the UK, Ireland, Austria, and the Czech Republic, while inHungary and Romania it seems to be widespread amongPWID.[1,27–30] In Romania, the spread of injecting cathinone useis also associated with the current HIV epidemic amongPWID.[27,28] The reasons for why this phenomenon affects somecountries more than others and what the determinants andconsequences of such an enduring change in patterns ofinjecting drug use are need to be further investigated.

Limitations

The presented data are not without limitations. Data on treatedinjecting drug users and NSP clients are not representative ofthe entire PWID population and are based on self-reported data.Furthermore, NSP data are not controlled for double-counting atnational level. DRD data provide information on detected casesonly. It is also important to note that due to the stigma relatedto drug use and to the resulting latency of the phenomenon, itis hard to define the actual coverage of DRD data. Nevertheless,since data collection methods did not change over the observedperiod, the detected trends can be regarded as indicative withrespect to emerging trends. Seizures data presented in the paperonly represent cases revealed by authorities and thereforeperhaps do not provide a fully representative picture of the drugsmarket. Seizures data on injecting equipment are not representa-tive either, however this is still the most reliable informationavailable on the substances actually injected.

Acknowledgements

The authors would like to thank the HNFP, the HIFS, and theNational Centre for Addictions for the data presented in thepaper. We would also like to acknowledge the efforts in datareporting of the Department of Forensic Medicine at SemmelweisUniversity and all NSPs providing data on their clients.



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Changes in patterns of injecting drug use in Hungary: a shift to synthetic cathinones