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Georgia buying MDMA pills

MDMA acts as both a stimulant and psychedelic, producing an energizing effect, distortions in time and perception, and enhanced enjoyment of tactile experiences. Adolescents and young adults use it to reduce inhibitions and to promote: euphoria, feelings of closeness, empathy, and sexuality. Although MDMA is known among users as Ecstasy, researchers have determined that many Ecstasy tablets contain not only MDMA but also a number of other drugs or drug combinations that can be harmful, such as: methamphetamine, ketamine, cocaine, the over-the-counter cough suppressant dextromethorphan DXM , the diet drug ephedrine, and caffeine. MDMA is mainly distributed in tablet form. MDMA tablets are sold with logos, creating brand names for users to seek out. The colorful pills are often hidden among colorful candies. MDMA is also distributed in capsules, powder, and liquid forms. MDMA use mainly involves swallowing tablets mg , which are sometimes crushed and snorted, occasionally smoked but rarely injected. MDMA is also available as a powder. MDMA abusers usually take MDMA by 'stacking' taking three or more tablets at once or by 'piggy-backing' taking a series of tablets over a short period of time. MDMA is considered a 'party drug. It is common for users to mix MDMA with other substances, such as alcohol and marijuana. MDMA mainly affects brain cells that use the chemical serotonin to communicate with each other. Serotonin helps to regulate mood, aggression, sexual activity, sleep, and sensitivity to pain. Clinical studies suggest that MDMA may increase the risk of long-term, perhaps permanent, problems with memory and learning. MDMA causes changes in perception, including euphoria and increased sensitivity to touch, energy, sensual and sexual arousal, need to be touched, and need for stimulation. Some unwanted psychological effects include: confusion, anxiety, depression, paranoia, sleep problems, and drug craving. All these effects usually occur within 30 to 45 minutes of swallowing the drug and usually last 4 to 6 hours, but they may occur or last weeks after ingestion. Users of MDMA experience many of the same effects and face many of the same risks as users of other stimulants such as cocaine and amphetamines. These include increased motor activity, alertness, heart rate, and blood pressure. Some unwanted physical effects include: muscle tension, tremors, involuntary teeth clenching, muscle cramps, nausea, faintness, chills, sweating, and blurred vision. High doses of MDMA can interfere with the ability to regulate body temperature, resulting in a sharp increase in body temperature hyperthermia , leading to liver, kidney and cardiovascular failure. Severe dehydration can result from the combination of the drug's effects and the crowded and hot conditions in which the drug is often taken. Studies suggest chronic use of MDMA can produce damage to the serotonin system. It is ironic that a drug that is taken to increase pleasure may cause damage that reduces a person's ability to feel pleasure. In high doses, MDMA can interfere with the body's ability to regulate temperature. On occasions, this can lead to a sharp increase in body temperature hyperthermia , resulting in liver, kidney, and cardiovascular system failure, and death. Because MDMA can interfere with its own metabolism that is, its break down within the body , potentially harmful levels can be reached by repeated drug use within short intervals. MDMA is a Schedule I drug under the Controlled Substances Act, meaning it has a high potential for abuse, no currently accepted medical use in treatment in the United States, and a lack of accepted safety for use under medical supervision. MDMA is a synthetic chemical made in labs. Ecstasy or MDMA. What are the street names? How is this drug abused? How does this drug affect the mind? How does this drug affect the body? What drugs cause similar effects? What are the overdose effects? What is the legal status in the United States? What are the common places of origin?

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Georgia buying MDMA pills

Official websites use. Share sensitive information only on official, secure websites. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. This study examines the effects of COVID related restrictions on the supply of illicit drugs, drug-use behaviour among people who use drugs PWUD regularly at least weekly , and drug-related service provision in Tbilisi, Georgia. In this mixed methods study, a cohort of 50 Georgian PWUD recruited through a snow-ball sampling participated in a bi-weekly online survey in April—September, They also took part in the qualitative telephone interviews at and week follow-up time points. In addition, four key informants field experts were interviewed monthly to assess their perceptions of changes in the illicit drug market and drug service delivery. Perceived availability of drugs was reduced during the lockdown, and many PWUD switched to alternative substances when preferred drugs were not available. On average, participants used significantly fewer substances over the course of the study, from 3. Consumption of cannabis products declined significantly aOR 0. PWUD cited fewer contacts with drug dealers, the lack of transportation, and the lack of conventional recreational environment as the main reasons for these changes. When access to sterile injection equipment was limited, PWUD exercised risk-containing injection behaviours, such as buying drugs in pre-filled syringes aOR 0. Harm reduction and treatment programs managed to adopt flexible strategies to recover services that were affected during the initial stage of the pandemic. COVIDrelated restrictive measures mediated specific changes in supply models and drug-use behaviours. While adjusting to the new environment, many PWUD would engage in activities that put them under increased risk of overdose and blood-borne infections. Harm reduction and treatment services need to develop and implement protocols for ensuring uninterrupted service delivery during lockdowns, in anticipation of the similar epidemics or other emergency situations. The COVID pandemic led to introduction of infection containment measures on both global and national levels. Growing evidence indicates that these measures have had a disruptive impact on illicit drug markets, affecting the availability and accessibility of drugs \[ 1 , 2 \]. People who use drugs PWUD may respond to such changes in drug markets and extraordinary social and economic situations by switching to new drugs, or modifying their drug-use patterns. These changes in the drug use can lead to increased health risks. For example, PWUD, while adhering to the rules of quarantine and restrictions on movement, can try purchasing drugs in larger quantities, and then consume them in larger quantities, or they may switch to more potent substances \[ 3 \]. This can increase the risk of overdose, specifically given the higher probability of using drugs alone \[ 4 — 6 \]. Those who consumed drugs largely in nightlife settings might reduce their use of specific substances such as alcohol, MDMA and cocaine and switch to alternative substances \[ 7 , 8 \]. With regard to drug supply during the pandemic, contactless drug dealing and online drug markets seem to play a more prominent role at the retail level \[ 9 , 10 \]. Regional reports, specifically from Eastern Europe, indicate that drug market disruptions may have resulted in increased small-scale clandestine production—and use—of amphetamine-type stimulants \[ 1 \]. Requirements for physical distancing and other COVID prevention measures such as reduced working hours, limited staffing, lack of transportation may have resulted in additional challenges for PWUD to access health care, including substance-use-related treatment and harm reduction services \[ 11 \]. In many countries, provision of harm reduction services was temporarily closed or reduced during the COVID lockdowns \[ 12 — 15 \]. In Georgia, the majority of drug-related data concern injection drug use. The research interest often driven by the priorities of international donors and public health focus has been directed towards the most risky pattern of drug consumption. With an estimated 52, people who inject drugs PWID , the prevalence of injection drug use in Georgia 2. In response, provision of treatment for substance use disorders and HIV prevention interventions, including low threshold harm reduction services, has expanded in the past decade. Across the country, harm reduction services for PWID are available through 18 fixed harm reduction sites and eight mobile van-based laboratories. In , such services testing and counselling, needle and syringe distribution, and other auxiliary services were provided to about 35, PWID. In , out of an estimated 20, opioid-dependent individuals in Georgia, more than 14, received opioid agonist treatment OAT , either with methadone or buprenorphine \[ 18 \]. Importantly, the data on non-injection drug use in Georgia are limited. Available research indicates growing use of new psychoactive substances NPS , which are increasingly available in the illicit market \[ 19 \], and the increasing use of psychoactive substances in nightlife settings \[ 20 , 21 \]. However, recent studies suggest the diffusion of alternative distribution models. Mobile phone applications e. The virtual dealers employ a common modus operandi—upon the receipt of the payment they provide the consumers with coordinates and a photo of the place where their purchase the drug has been hidden in advance dead drop. Finally, social supply plays a prominent role in the Georgian drug scene. Individuals who use cannabis, those using NPS, and festival and nightclub attendees report that in a majority of cases drugs were obtained from friends \[ 19 , 24 , 25 \]. Restrictive measures included some form of lockdown, border closings, restriction of movement, closure of businesses and educational institutions, and curfew. The restrictions were gradually removed starting from June , but were partially reintroduced in November in response to a surge in new infections. To our knowledge, the modern research aiming to understand the impact of COVID pandemic on drug markets, patterns of drug consumption and drug-related service provision has mostly relied on cross-sectional data gathered through one-time online surveys among samples from general population or specific groups of PWUD. These findings therefore are limited to the specific time points of the lockdown and do not provide understanding of medium-term trajectories of drug consumption. In most cases, findings are further subject to limitations and biases associated with online recruitment and data collection \[ 26 , 27 \], but also with retrospective examination of behaviours \[ 28 \]. The current study aimed to examine changes in drug taking behaviours, drug supply and drug-related service delivery over the first six months of the pandemic through collecting prospective longitudinal data from the cohorts of PWUD who consumed drugs regularly in Georgia and Ukraine. The quantitative data were combined with qualitative methods to enrich our understanding of the context and mechanisms of the observed changes and to possibly identify factors that may have contributed to those changes. This article reports findings from the Georgian study cohort. We utilized a sequential explanatory design for this mixed methods study in which the qualitative data were used to explore quantitative findings \[ 29 , 30 \]; quantitative data were collected first and guided qualitative data collection. This approach ensures complementarity of the results from one method with the results from the other, where qualitative results provide contextual understanding of the processes underlying the quantitative outcomes and explain quantitative observations \[ 31 , 32 \]. Quantitative and qualitative data were analysed separately, and the integration occurred during the results presentation and interpretation, so that the findings from the two methods interweave within specific subsections each of which focuses on one aspect of the research question \[ 33 , 34 \]. The research team used a purposive snow-ball sampling with eight relatively heterogenous seeds—individuals who use drugs through injection and non-injection routes and individuals who use drugs in nightlife settings, including representatives of the LGBTQ community—to recruit PWUD in Tbilisi. Seeds were identified through the outreach workers of low threshold HIV prevention programs. The seeds recruited eligible participants using a chain referral sampling snow-ball approach. The research team has never met face-to-face with initial seeds or the rest of the PWUD sample. We determined eligibility through the phone interviews and relied on the extensive experience of the research team in this process. Apart from the comprehensive screening instrument, researchers used probes e. The sample size was determined based on the available funding to support the research staff and provide incentives to the study participants. Regular drug use was defined as at least weekly use of a psychoactive substance except cannabis or alcohol in the prior six months. Other eligibility criteria included being 1 18 years or older; 2 fluent in Georgian; 3 having reliable Internet access; 4 being willing to provide their cell phone number for communication and research data collection interviews. We excluded those PWUD whose sole use of illicit substance was cannabis. Cannabis use in combination with other illicit drugs, use of licit psychoactive substances prescription psychotropic medications and antihistamines with psychoactive effect , and use of alcohol was of interest for the study, and relevant data were collected. Therefore, whenever cannabis use is reported in the results, it is in all instances a combination use with other illicit psychoactive substance s. To collect quantitative bi-weekly data, we used a free online platform Kobotoolbox. Participants had a 3-day window period to log in and complete the survey. In the morning on every data collection time point, each participant received SMS-reminders with the survey link, session number and participant ID. The questionnaire is available in the Additional file 1. Prior to launch, the survey tool was test-piloted with the PWUD who had similar characteristics as the potential study participants. Demographic information included age, gender, education, employment status, and source of income. Other outcomes of interest included source s of drugs, perceived changes in their price and quality, frequency of use, history of overdose, access and use of treatment and harm-reduction services. Details of outcome variables, measures and assessment time points are presented in Additional file 1 : Table S1. To collect the qualitative data, two research assistants conducted telephone interviews with all PWUD cohort participants at and week time points. The interviewer covered topics related to the perceived changes in drug supply and drug-use behaviours, and factors influencing them. With the consent of respondents, the interviews were digitally recorded. Timeline of the data collection events is presented in Additional file 1 : Fig. Apart from the PWID cohort, four key informants were recruited from the pool of individuals working in the field of psychoactive substance use in Tbilisi. The key informants were interviewed by the first author at the end of each study month six interviews with each respondent via phone and were asked to provide information about changes in drug market, drug-user behaviour and service delivery during the preceding month. The qualitative interview guide covered the following domains: drug markets availability, supply channels, quality, price ; behaviour of PWUD with regard to drug procurement and consumption; risk-containing behaviours; availability and use of drug-related health services. Interviews typically lasted 15—30 min and were recorded with the permission of the respondents. Key informants were not the part of the PWUD cohort, so no data collected from key informants were used in quantitative analysis. The sociodemographic and behavioural profile of PWUD study participants was described using frequencies and proportions for categorical variables , and mean values for continuous variables, as appropriate. The original study protocol foresaw testing of hypothetical inflection points—corresponding to the major disruption or change in social patterns caused by the pandemic—for the key variables of interest, using spline regression models or similar methods. However, an interim analysis revealed that the use of different substances and other variables changed inconsistently over time, and a joint hypothesis could not be defined. As an alternative, we chose a hypothesis of linear trend, to assess whether substance use, behaviours and services increased or decreased significantly during the study period. To account for within-subject autocorrelation across time points, we used mixed effects generalized linear models. The assessment number, ranging from 1 to 13, was used as a continuous variable representing time. Adjusted Odds Ratios aORs for the assessment number represent an incremental increase or decrease in the estimated likelihood of achieving the outcome in the subsequent assessment; significant aORs indicate a decrease or increase in the given variable over the study period. The models were adjusted for the duration of drug use, sex, and baseline lifetime exposure to OAT. The analysis was done using R software version 4. For the qualitative component of the study, two research assistants the same who conducted qualitative telephone interviews transcribed recordings verbatim. Data were analysed using NVivo v. We relied on a framework analysis approach for this study \[ 41 \]. The framework method is an effective tool to support thematic qualitative content analysis and is most suitable for the analysis of the interview data, where researchers expect to generate themes by making comparisons within and between cases. Importantly, framework method facilitates management of large data sets through its matrix form which provides an intuitively structured overview of the summarized data. Following the reading and rereading of the textual data, the list of key themes was developed. A set of codes that were organized into categories was agreed and applied to all transcripts. However, if new ideas and new ways of categorizing were identified in the text, the list of hierarchical codes was amended. This approach helped to identify commonalities and differences in data and to draw descriptive and explanatory conclusions clustered around themes. There were 13 sessions for the online quantitative survey with PWUD, conducted every other week starting on April 7 and ending on 24 September One participant dropped out after the sixth session. Overall, of the planned sessions, 40 sessions 6. There were 40 individual qualitative interviews conducted with PWUD participants at the week follow-up time point, and 34 interviews conducted at the week follow-up. No interviews were missed with the key informants—in total, there were 24 individual telephone interviews conducted with the drug field experts four interviews each month. Digital informed consent was obtained from all respondents. No identifiable personal information was collected from the PWUD cohort participants. Datasets for the current work are publicly available through Mendeley Data \[ 42 \]. Five participants in the study cohort were on OAT at baseline, and stayed in treatment until the end of the data collection. Six participants initiated OAT during the study. Over the course of the study, 27 participants reported having being tested for COVID and none was positive. At baseline, cannabis products were the most frequently used substances in the preceding 12 months. These were followed by heroin and alcohol. There was a number of observable trends in relation to the past day consumption of various substances during the period studied, as shown in Fig. Buprenorphine diverted from OAT programs was the third most prevalent substance used at baseline. Analysis via mixed effect models indicates a statistically significant descending trend in consumption of cannabis products, alcohol, amphetamines, diverted medicinal methadone, diverted medicinal buprenorphine, Ketamine, LSD and myorelaxants see Table 2. The number of different substances used by the participants also declined significantly over the course of the study, from on average 3. Statistically significant results of mixed effect models a for testing an association between specific outcomes of interest and time assessment number. Results describing frequency of drug use were mixed, with some respondents reporting higher frequency of consumption at some points, and others reporting lower frequency of use. Overall, we did not observe any statistically significant trends in the frequency of drug consumption. Similarly, the results with regard to amounts of drugs consumed were mixed. Qualitative interviews provided useful insight into the changes in drug use behaviour of study participants. The reduced availability of preferred substances in some instances caused users to look for alternative substances. In some cases, these were substances that were familiar to individuals and had been used at some point earlier in their drug history. In other cases, individuals switched to the substances that they had never tried before. In addition, many individuals consumed only substances that were readily available to them:. I use now what is available. For example, a lot of cannabis and Ketamine. I have never used Ketamine so often. I now tried vint as well. I would not use it if other drugs were available. I had lot of free time, there was nothing to do, no hanging out with people, and lot of depression around, so you need more drugs to deal with depression… I can say that I used vint and psychedelics more often at that time, and smoked pot really too much. On the other hand, those who reported reduced frequency of drug use referred to difficulties in obtaining drugs, high prices and low quality as their main reasons. For some users, the principal reason for less frequent use was the closure of nightclubs and other spaces where they frequently consumed drugs:. I usually used drugs in clubs, sometimes at home. I was buying for overnight club use. Now clubs are closed and I even do not buy drugs and only use when someone offers. In the quantitative online survey, the majority of participants reported relatively stable quality based on their perceptions and price for most drugs over the course of the study. Over the course of the study, the proportion of participants reporting their perception of price increases gradually declined. In other words, with each consecutive assessment, more respondents indicated that the price of their main drug did not increase, and this trend was statistically significant aOR 0. When looking into the data on exact prices paid by participants for various drugs, the picture is heterogenous. Throughout April—September, price paid for a single dose of a specific drug increased to different degree for heroin, diverted medicinal methadone, and psychotropic sedatives. However, these trends were not statistically significant. The quantitative data suggest that the perceived availability and access to the main drug of choice were strongly affected, particularly during the strictest lockdown period in April—May, However, towards the end of the study, an increasing number of respondents reported that obtaining their main drug of choice was not getting more difficult. This trend was statistically significant aOR 0. In the qualitative interviews, the opinions about changes in price and quality of drugs were ambiguous, with some respondents believing that the price for most substances increased steeply during the lockdown:. Absolutely everything \[is more expensive now\], except for opiates. With regard to access to drugs, for many respondents, the reduction in the availability of drugs was particularly evident for stimulants and cannabis products. Others suggested that the most affected in terms of availability substance was heroin, which was largely procured via person-to-person contacts with dealers. Further, respondents noted that there were fewer sellers and a reduced variety of drugs offered through online markets. The qualitative interviews further indicate that participants observed an increase in the availability of methadone and buprenorphine diverted from OAT programs. As stated by the respondents, these were both sold by OAT clients and supplied through friendship networks for free:. Suboxone and methadone from programs were easy to get, they \[ patients \] received medication to take home and they easily sold it. The participants also suggested that some sellers made adjustments with regard to places where dead drops were hidden. In many cases locations for dead drops moved to Tbilisi suburbs, quiet places where there was a less police movement and surveillance. In some cases, when drugs were bought from online markets, the dead drops were not in places indicated by online sellers, or a customer could not access the location. Often, it was difficult to move in the city due to a lack of transportation options, restrictions that were introduced by the government. The police presence on the streets also increased, hence going to pick up dead drops and moving with drugs through the city was perceived as more challenging and risky. For example, users who were able to pay for drugs and who wanted to avoid excessive in-person contacts, employed other users who would take the risk associated with drug delivery in exchange of a personal dose. Results of the quantitative survey demonstrate that there were remarkable variations in the ways specific drugs were acquired by study participants. Antihistamines used in combination with opioids to enhance and prolong their effect , psychotropic muscle relaxants, and sedatives were mostly obtained from pharmacies. We did not find any statistically significant changes in how any specific drug was acquired over the study period. In qualitative interviews, many respondents stated that they were unable to keep stable contact with the dealers, so they had to look for new sources repeatedly:. I can say that we look for new channels almost every day. Trying this, trying that. In doing so, participants explored novel schemes for purchasing drugs during the lockdown period. For example, it was possible to receive drugs delivered to your home:. The quantitative survey included several questions covering potentially high-risk injection behaviours. During the same period of the strictest lockdown April—May, , more than a quarter of participants reported obtaining drugs in pre-filled syringes. However, the most prevalent risky practice was related to sharing common instruments for preparation and injection of drugs—see Fig. During the strictest lockdown, almost half of the sample did share equipment with others at least once in the preceding 14 days. Sharing practices ceased as soon as lockdown measures were eased, and access to sterile equipment was restored. In a mixed effect model analysis, the odds of receiving drugs in a pre-filled syringe decreased with each consecutive assessment aOR 0. Over the same period, increased odds of always having a new syringe for injection was marginally significant aOR 1. Around two thirds of participants reported using some harm reduction services while participating in the study. Participants acknowledged that access to programs was particularly affected during the first two months of the study April—May, —the strictest lockdown period , and then gradually recovered. Based on the results of the mixed effects model, the trend in perceived improvement in accessibility of harm reduction services was statistically significant aOR 0. Qualitative interviews indicated that access to needle and syringe programs became problematic because harm reduction sites reduced working hours and had to comply with social distancing requirements. Provision of voluntary counselling and testing services was particularly affected. Those respondents who were using harm reduction services noted that programs made reasonable adjustments to their operations and employed flexible strategies to ensure continuous provision of services. For example, services extensively used mobile vans and prioritized offering HIV self-testing to their clients. One respondent noted that he would call his social worker who would bring sterile equipment to his place:. Access was limited at the beginning. Yes, when offices were closed, I was calling my social worker, so he would bring syringes to my home. Finally, key informants shared their observation that the overall demand for OAT increased in April and May Among other factors, the rise in demand was related to the lack of traditional opioids on the market, but also to the attractiveness of OAT with at-home dosing. As a summary of the key findings of the study, Table 3 provides presentation of the key results of our mixed methods approach. Results of our study suggests that COVID related restrictive measures and changes in illicit market dynamics resulted in shifts in drug use behaviours. Many PWUD switched to alternative substances, when their preferred drugs were not readily available. Others reduced the frequency of drug use due to the difficulties in obtaining their favourite drugs, or because the setting in which their drug use usually occurred night clubs and music festivals was not there anymore, due to mandated restrictions on gatherings in such settings, as part of COVID control efforts. These shifts in drug using behaviours among nightlife attendees have been noted by other authors; Zaami et al. European data indicate that use of MDMA and cocaine common party drugs may have declined due to the closure of nightclubs, while use of cannabis has remained relatively stable \[ 2 , 9 \]. The US-based studies suggest that although recreational drug use may have declined due to COVIDrelated restrictions, many electronic dance music partygoers who use drugs would attend virtual raves and virtual happy hours \[ 8 \]. A cross-European study that analysed wastewater samples in seven cities in the Netherlands, Belgium, Spain and Italy at the beginning of lockdowns March—May found that there was a decline if compared to previous years in illicit drug consumption for some substances and locations e. In the studies in Germany and Switzerland, most participants reported no change in their drug consumption, and authors concluded that at least at the early stage of the pandemic enforced restrictions did not substantially impact the demand and consumption of illicit drugs \[ 45 , 46 \]. Overall, the situation in the early COVID period was highly heterogenous in most of the jurisdictions for which data were available, so it was difficult to draw definite conclusions regarding the impact of the pandemic on illicit drug use. In our study, there was a general perception among PWUD respondents and key informants that it was more difficult to obtain drugs, especially during the strictest lockdown, compared to the pre-COVID time. The main reasons cited were the lack of transportation, increased police presence, and difficulties to maintain contacts with drug dealers. However, opinions with regard to which drugs availability was affected most were mixed. Overall, our data suggest that the perception of a reduced availability did not correlate much with the actual use of particular substances. This in part might be explained by the fact that in many cases individuals were able to find alternatives to their preferred substances when they became unavailable. Our findings regarding perceived changes in the price and quality of drugs were not definitive, although the majority of participants believed that the overall tendency was an increase in prices and decrease in a quality of substances available on the market. However, the quantitative data reported by participants on prices paid for specific drugs did not show any significant trends. In addition, at certain assessment points, some substances e. Preliminary data from the E. In an Australian study, market indicators use of specific drugs, perceived availability and purity remained relatively stable for most drugs, although there was some evidence of perceived reduction in the availability and purity of cocaine, methamphetamine and MDMA \[ 47 \]. Authors suggested that reduction in the use of MDMA and other stimulants was mainly associated with the impediments to socialization. Similar to these findings, the study in Switzerland did not find any significant changes in the purity and availability of drugs on a local drug market \[ 46 \]. Study participants noted an increase in the availability of diverted medicinal methadone and buprenorphine on the market, which followed from an unprecedented—for Georgia—decision to allow for 5-day take-home dosing of these medications for all OAT patients. Both substances were diverted by OAT patients, and were distributed free to friends or sold through personal networks of people who use drugs. The scale of this phenomenon however remains unclear. It is also unclear whether this development initiated drug use by new users, or relapse among those with a history of drug use. Results of this study did not show any increase in the use of diverted substitution medications in the study sample. Both medicinal methadone and buprenorphine were used by the study cohort i. On the contrary, the prevalence of use of medicinal methadone declined by the time of the last interview session. Again, it is difficult to unambiguously determine if this decline was caused by the reduction in the availability of medicinal methadone on the market after take-home dosing was banned again in the beginning of September In a Canadian study, authors suggest that following the adoption of flexible protocols and expansion of take-home dosing, the reduction in directly observed dosing may have posed a risk to public safety, due to diversion of prescribed medication and its non-medical consumption \[ 3 \]. Respondents OAT care providers in that study also expressed concerns over the increased risk for overdose given that some clients might have consumed higher doses of OAT medication or use illicit drugs in combination. However, the study in Australia did not find an association between the expansion of take-home dosing and increase in substance use \[ 49 \]. Obviously, there is a need to find a balance between strict infection control measures and monitoring, to mitigate the risk for negative health effects and diversion. We identified certain changes in drug supply models. For example, for drugs that were purchased through online platforms via dead drops, drop locations were moved to Tbilisi capital city suburbs and isolated locations to avoid detection by the law enforcement while police presence was intensified in central districts of the city. When stable contacts with dealers were adversely affected by pandemic-related restrictions, users searched for new contacts and supply options. In doing so, previously closed PWUD networks started interacting with each other, and in some cases merged, in an attempt to identify new channels of drug supply. PWUD with financial resources recruited middlemen, in order to reduce legal risks associated with illicit transactions and to limit their exposure to virus transmission. Overall, the role of middlemen increased, and they seemingly became important players in the altered drug market landscape. Similar to our findings, researchers in Germany reported a specific change in drug distribution methods. While before COVID customers were going to their dealers to procure drugs, following the introduction of restrictions, drug dealers adapted supply methods and began deliver drugs drop off to their clients \[ 50 \]. Our findings, along with the findings of other authors indicate that drug market players both dealers and consumers showed remarkable flexibility while adjusting to altered drug market landscape and market conditions. Results of this study suggest that when access to sterile injection equipment was limited due to restrictions on movement and scaled down provision of harm reduction services, PWUD exercised risk-containing injection behaviours. The first weeks of lockdown were accompanied by a rise in risky practices, in particular receiving used syringe and sharing instruments and tools for drug preparation and division. Such practices, however, were abandoned as soon as lockdown measures were relaxed and access to sterile equipment restored. In other words, individuals who consume drugs through injection showed awareness of risk limiting practices and demonstrated their ability to take care of their health when basic supportive services were available. Countrywide, there was a six-fold reduction in a number of HIV rapid tests performed in April compared to February vs. These findings underscore the critical importance of uninterrupted services provision to vulnerable populations, and the challenges that service providers face with providing continuous care. Available research indicates that in many countries, PWUD experienced reduced access to their usual drug-related services during the pandemic, including limited access to OAT and testing for blood-borne infections \[ 1 \]. In Spain, harm reduction centres had to reduce operating hours and work at reduced capacity during the lockdown; testing for infectious diseases and access to care were seriously disrupted \[ 13 \]. In the US, of the 65 NSPs queried, 10 discontinued all operations, and 16 switched to mobile operations \[ 14 \]. Our findings indicate that despite some interruptions in service delivery during the first weeks of lockdown, harm reduction programs showed remarkable flexibility and were able to effectively deliver services. In this situation, SVMs proved to be an effective means for uninterrupted provision of sterile equipment while ensuring no-contact service delivery. Detoxification treatment was also affected during the strictest lockdown measures. Use of these services, however, recovered when those measures were lifted. Demand for OAT increased when pandemic-related restrictions were enforced. Apparently, reduced access to illicit drugs and attractiveness of take-home dosing were drivers that contributed to the rise in demand. OAT programs were able to adjust quickly and effectively to changed circumstances; new clients were admitted to treatment and take-home dosing was implemented. Similar to our findings, international research indicates that the utilization of novel forms of service delivery was broadly adopted during the pandemic. For example, the use of telemedicine increased dramatically over the first months of implementation of COVIDrelated restrictive measures \[ 55 , 56 \]. Innovative solutions have been introduced to reduce viral transmission risk by reducing physical contact between providers and clients, for example MySafe devices for dispensing medications through a confirmatory biometric scan of the palm \[ 57 \], virtual individual or group therapy sessions \[ 58 \], home delivery of services e. Our quantitative data were collected via online platform, and we had no means to verify the identity of participants in the bi-weekly surveys. However, we did not identify major inconsistencies across the longitudinal data points and believe that the risk of someone else not the study participant filling out the questionnaire was minimal to non-existent. Our data are limited to the first six months of COVID lockdown, and thus, the observed trends might have changed after the data collection period. In addition, the study sample, consisting of the residents of the capital city with easy access to mobile technology, may not be representative of all people who use drugs in Georgia. Other individuals who live in remote areas, might have responded differently to the changes in the context overall, and in illicit drug markets in particular. In addition to the small sample size, some drugs were used infrequently, which might further affect generalizability of the results, specifically with regard to the less popular used drugs. Nevertheless, our aim was not to obtain statistically robust estimates of prevalence of specific types of drug use. We instead aimed to detect changes in behaviours of PWUD and to understand the factors that drive those changes. The mixed method approach used for this study allowed us to achieve synergy and provide better understanding of the observed trends and the rationale behind them. The qualitative data collected from the field experts key informants contributed to this approach and provided valuable insights. This study contributes to the understanding of how drug use behaviours and service provision adapted to the extraordinary situation caused by the COVID pandemic. Changes in supply models and drug-use behaviours indicate that many PWUD will engage in activities that put them under the increased risks of overdose and of acquiring blood-borne infection. There are several important public health implications that can be drawn based on this study. Harm reduction and treatment services can improve sustainability of service delivery by implementing clear protocols that can be enforced in any future response to epidemics or other emergency situations. Such protocols should build upon the experience accumulated during the COVIDrelated restrictions, such as flexible dosing of medication, utilization of HIV self-testing technologies, mobile van-based outreach, and vending machines for dispensing sterile injection equipment. In addition, prevention and education components of these services should include information to raise the awareness of PWUD about the risks identified in this study, such as increased injections from pre-filled syringes. OAT programs need to develop and implement clear and flexible procedures for medication take-home dosing, to ensure a balanced approach to medication dispensing practices while controlling risks for diversion and poor patient outcomes. Additional file 1. Study questionnaire and outcome variables, measures, and assessment time points. DO involved in conceptualization, methodology, investigation, validation, data curation, formal analysis, supervision, and writing—original draft. IK involved in conceptualization, methodology, validation, data curation, formal analysis, supervision, writing—review and editing. All authors read and approved the final manuscript. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Harm Reduct J. Find articles by David Otiashvili. Find articles by Tamar Mgebrishvili. Find articles by Ada Beselia. Find articles by Irina Vardanashvili. Office 20, 27, Kyiv, Ukraine. Find articles by Kostyantyn Dumchev. Find articles by Tetiana Kiriazova. Find articles by Irma Kirtadze. Received Jun 3; Accepted Feb 17; Collection date Open in a new tab. As access to sterile apparatus improved, PWID returned to safer injection behaviours Lack of access to sterile injection equipment, new practice of supply in preloaded syringe Access to harm reduction services was strongly affected during the initial phase of the lockdown and improved later as providers adopted flexible approaches and models of service provision Closure of provider organizations followed by the adoption of innovative service delivery models. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Reduction in use of cannabis, alcohol, amphetamine, medicinal methadone, medicinal buprenorphine, Ketamine, LSD, myorelaxants. Affected contacts with dealers, lack of transportation and restrictions for movements curfew. Perceived increase in prices at the beginning of the lockdown and stabilization of prices or return to initial figures following the removal of restrictions. Injection-related risky practices increased during the initial phase of the lockdown. As access to sterile apparatus improved, PWID returned to safer injection behaviours. Lack of access to sterile injection equipment, new practice of supply in preloaded syringe. Access to harm reduction services was strongly affected during the initial phase of the lockdown and improved later as providers adopted flexible approaches and models of service provision. Closure of provider organizations followed by the adoption of innovative service delivery models.

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