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Harm Reduction Journal volume 11 , Article number: 17 Cite this article. Metrics details. An injecting mix of medicines like opioids, benzodiazepines and antihistamines the so-called South Asian cocktail was prevalent. Furthermore, it is estimated that about 70, people are living with human immunodeficiency virus HIV. The government of Nepal has started realizing and recognizing drug use and HIV as significant health and social issues. Harm reduction programs such as needle syringe exchange and opioid substitution treatment are being implemented. The aim of this study is to obtain specific knowledge on the drug use behaviour and the health status of drug users with a focus on HIV in drug users with concurrent injection of opioids, benzodiazepines and antihistamines. After an initial mapping of Kathmandu Valley, drug users in contact with different treatment and counselling centres were randomly chosen for the interviews. Mean age is Ninety-five percent are injecting drug users with a mean of 8. Compared to the other drug users mainly heroin , the cocktail users show a higher HIV infection rate and more co-infections. Furthermore, risk behaviour, as e. Currently, the mixture of medicines, opioids, benzodiazepines and antihistamines, is the predominant drug in Nepal; the pharmaceutical drugs needed to prepare the cocktail are less expensive than heroin and relatively easy to acquire. The cocktail users show a higher risk behaviour regarding the transmission of HIV than heroin drug users. It needs to be considered which HIV prevention measures are necessary to target the specific needs of drug users who inject a mixture of opioids, benzodiazepines and antihistamines, since the available services such as needle syringe exchange do not seem to cover their specific needs high percentage of needle sharing. People who use drugs are at risk of getting infected with human immunodeficiency virus HIV and of transmitting the infection to other drug users via needle-syringe sharing or to their sex partners through unsafe sex. Injecting drug users can act as a bridge to transmit HIV to others with whom they have sexual contacts. Numerous studies have found IDUs to be disproportionately likely to be involved in unsafe sex practices \[ 2 , 3 \]. Sex workers male and female , who offer sex in exchange for money or drugs, are at high risk for HIV infection and can spread the virus to a large number of people. In addition, sexual contact between IDUs and non-injectors may also contribute to an increased incidence of HIV infection. As a result of high-risk sexual behaviour, HIV is also a risk among drug abusers who do not inject drugs. Until the s, injecting drug use was rare in Nepal. With the introduction of pharmaceutical drugs such as buprenorphine, benzodiazepines, chlorpromazine and dextropropoxyphene, a transition took place, away from smoking or chasing heroin and towards injecting drug mixtures, mainly of buprenorphine mixed with benzodiazepines and chlorpromazine, as well as other antihistamines—the so-called South Asian cocktail. Polydrug use appeared to be the norm ranging from alcohol to heroin , and transition from non-injecting to injecting behaviour appeared to be linked to the need for choosing the most cost-effective route of administration \[ 4 \]. Most of them are male A major share of this number, i. It is estimated that in Nepal, 70, people are living with HIV \[ 6 \]. The impact of many types of psychoactive substances, including alcohol, and regardless of the fact whether they are injected or not is risky to the extent that they are dis-inhibitors and affect the individual's ability to make decisions about safe sexual behaviour. According to Larance and colleagues, buprenorphine has reportedly emerged as the favoured drug of injection among IDUs \[ 9 \]. Also, in India, an increase in the consumption of prescription opioids such as buprenorphine, codeine and dextropropoxyphene among drug users has been observed in the past decade \[ 10 \]. This so-called cocktail use behaviour has created health, social, economic and legal hazards to IDUs. The coverage of opioid substitution treatment OST in Nepal is comparatively low, and high-risk injecting and sexual behaviour among IDUs continues. The financing of OST is largely provided by external donors, and donations have become scarce with the current global economic problems \[ 11 \]. A cross-sectional survey among opiate users in contact with the treatment system was conducted. As the research focuses especially on concurrent use of opioids, benzodiazepines and antihistamines, Kathmandu Valley was selected for this survey due to its high concentration of illegal and opiate drug users, including injecting drug users. Patients were randomly chosen from the lists of the respective treatment facilities. If a person refused to take part in the interview the next patient on the list was asked to participate. Altogether drug users IDUs were interviewed for this study. The sample size was determined by the expedience method, thereby including those items readily available or convenient to collect. As the research focuses on illegal drug users, only persons in contact with rehabilitation centres, treatment centres, OST clinics and counselling services were included in the study. Centres from Kathmandu, Lalitpur and Bhaktapur were visited to collect information. Six trained interviewers conducted structured interviews with the participants. After piloting with five respondents, only slight changes were made to the questionnaire. Prior to the study, the interviewers received special training on the content of the interview, the organization of the centres and how to communicate with the drug users. The interviewers requested information on patients' socioeconomic characteristics age, gender, years of education, marital status and job status , addiction history prior to treatment entry: all drugs used for at least 1 month in their lives, routes of administration, the main drug of abuse the most problematic drug, i. The interviewers conducted the interviews in cooperation with the staff of the centres who encouraged the selected patients to participate. Patients usually spent some time in the waiting room before visiting the counsellor, receiving their medication or visiting their doctor, thus providing a good opportunity for the interview. The interviewers explained the study to the drug users individually and inquired about their willingness to participate. The data collection in each facility or clinic was continued in order to reach all patients that visited the institution within 1 month. The data collection was carried out using an anonymous patient characteristic form which aimed at providing as much confidentiality as possible. The study was voluntary, and all respondents provided their written informed consent. With respect to the consumption of drug mixtures, the study participants were divided into three groups. The data were transferred from the paper forms to a digital format. One tenth of the drug users are in contact with drop-in centres. The majority of drug users were working or in training before entering treatment; only one third was unemployed. Eighty-three percent of HIV-positive drug users have co-infections of hepatitis C. The mean score of physical health problems according to MAP range 0—4 is 1. Cannabis is the most frequently consumed illegal drug among the drug users of Kathmandu Valley. Risk behaviour is very common, i. Thirty-four percent take those mixtures of drugs on a moderate less frequent basis see below. Differences between sample characteristics regarding the intensity of concurrent drug use are shown in Table 1. First of all, a significantly higher proportion of men can be found among the users of drug mixtures. Intravenous drug use, at least once in life, was found in all cocktail users, i. With respect to co-infections, the prevalence is significantly higher among intensive cocktail users, compared to both other groups of drug users. Similarly, the prevalence of mental health problems is also significantly higher among intensive users of mixed drugs. Forty-five percent of the drug users took three or four different cocktails in the past 30 days. According to the results of the interviews and respondents' statements, the following different types of substance mixtures are consumed by the drug users in Kathmandu Valley. On the other hand, it can be shown that different types of substance combinations are used by the same person. The mean number of different cocktails used is 2. Based on the persons with concurrent use of different drugs only, the mean number is 2. Different kinds of cocktails are usually consumed several times a day. Empirically, the mean number of different cocktails consumed in this group is 3. Thirty-four percent take opioids in combination with other drugs on a moderate less frequent basis. Their mean number of cocktails used during the past 30 days is 1. Data on drug use and risk behaviour during the past 30 days was collected from the respondents. Table 3 gives us a picture of the situation. However, heroin use among intensive cocktail users is significantly higher than in moderate users. Cannabis is more commonly consumed among the groups with combined drug use, whereas only the difference between non-cocktail users and moderate users reached statistical significance. Table 3 reveals that chewing tobacco is also a highly used drug among the intensive users of mixed drugs. With respect to risk behaviour, the study shows that because needle sharing is significantly more common among intensive cocktail users, they are at a higher risk than moderate users and non-users. Similarly, intensive users also share other equipment very frequently. In both groups of users of mixed drugs, higher percentages of persons than in the non-user group use the same needle several times. In summary, it can be stated that especially intensive users of opioids in combination with other drugs practice risk behaviours significantly more often than the remaining groups. For the intake of these drug cocktails, all drug users use syringes. The substances contained in the cocktails are obtained from different sources. Differences in drug use and risk behaviour become apparent when persons with and without HIV infection are compared Table 4. Furthermore, a strong association between HIV status and risk behaviour can be shown. It provides current and specific knowledge on the status of HIV and other infections. The pharmaceutical drugs needed to prepare the mixture are less expensive than heroin and relatively easy to acquire. The drug users who consume opioids in combination with other medical substances have a higher risk behaviour than heroin drug users which is associated with the spread of HIV. It needs to be considered which HIV prevention measures are needed related to the specific needs of the so-called cocktail users, since the available services such as needle syringe exchange do not seem to cover their specific needs high percentage of needle sharing. Respectively, it is necessary to identify why the available HIV prevention services e. The level of OST coverage in Nepal is relatively low. As presented in the systematic review by Mathers et al. Although the number of OST clinics increased from three to five in with a maximum number of treatment slots, the coverage is still only about 2. Especially diazepam has a long half-life period which produces a cumulative effect in the body. This indicates a much higher need for a comprehensive treatment approach in the region which provides the opportunity to offer appropriate treatment for other mental and somatic symptoms. This study is the first of its kind to understand the situation of the so-called cocktail drug use in Nepal, and its results have shed some light on the circumstances of this special kind of combined drug use. At the same time, this research has detected the following more specific research needs: What is the specific situation of cocktail drug users with HIV infection? Furthermore, the specific role and effect and possible risks of the antihistamine within the mixture of substances has to be investigated. Research also reveals that the substances for the drug mixture are catered by drug stores and chemists. This indicates a significant need for awareness raising among drugstore keepers, in order for them to understand the consequences of selling these drugs without a proper prescription. With respect to harm reduction services and treatment offers, the question arises to what extent cocktail drug users utilize and benefit from harm reduction programmes. Furthermore, as buprenorphine is found to be the main substance involved in intravenous abuse of mixed drugs in Nepal, a need for scaling up buprenorphine substitution treatment within the OST program in Nepal has to be considered. One limitation of our study is the choice of the sample which only consists of persons who are in contact with drug services or treatment. Thus, no information on drug users without professional support can be obtained, and we do not know how much we can extend these findings to the other substance users in Nepal. This would be of particular interest, as the majority of drug users in Nepal are not reached by special services. Round V -. Google Scholar. J Acquir Immune Defic Syndr. Clin Infect Dis. Summary from a Needs Assessment Study. Drug Alcohol Rev. Article PubMed Google Scholar. Indian J Med Res. Int J Drug Policy. Eur Addict Res. Article Google Scholar. Core System Manual. Download references. We thank the patients and staff who have participated in the study for their support. You can also search for this author in PubMed Google Scholar. Correspondence to Uwe Verthein. SS carried out the data collection. All authors read and approved the final manuscript. Reprints and permissions. Ojha, S. Harm Reduct J 11 , 17 Download citation. Received : 26 September Accepted : 06 May Published : 23 May Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. Download ePub. Methods The aim of this study is to obtain specific knowledge on the drug use behaviour and the health status of drug users with a focus on HIV in drug users with concurrent injection of opioids, benzodiazepines and antihistamines. Conclusion Currently, the mixture of medicines, opioids, benzodiazepines and antihistamines, is the predominant drug in Nepal; the pharmaceutical drugs needed to prepare the cocktail are less expensive than heroin and relatively easy to acquire. Introduction People who use drugs are at risk of getting infected with human immunodeficiency virus HIV and of transmitting the infection to other drug users via needle-syringe sharing or to their sex partners through unsafe sex. Methods Subjects A cross-sectional survey among opiate users in contact with the treatment system was conducted. Face-to-face interviews Six trained interviewers conducted structured interviews with the participants. Ethical approval The data collection was carried out using an anonymous patient characteristic form which aimed at providing as much confidentiality as possible. Statistical analysis With respect to the consumption of drug mixtures, the study participants were divided into three groups. Acknowledgements We thank the patients and staff who have participated in the study for their support. View author publications. Additional information Competing interests The authors declare that they have no competing interests. About this article. Cite this article Ojha, S. Copy to clipboard. Contact us Submission enquiries: journalsubmissions springernature.

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