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Jason Kane Jason Kane. Victoria Fleischer Victoria Fleischer. Malindi, Kenya: A vacation destination with something for everyone. Sitting on the crystal coast of east Africa, the resort town offers glass-bottomed boat cruises, authentic Italian pasta, sex-for-hire and dirt-cheap heroin. But during the low season — the four months of the year when rain is more frequent and the hotels empty out — things turn darker here. When times are good, the business gives him enough cash to shoot heroin five or six times per day. The effect: Unintentional detoxification. Buska Ismail fights the pain as a clinical officer applies antiseptic to a severe wound on his back. Sometimes, Buska can only afford to shoot once per day, triggering withdrawal symptoms like abdominal pain, nausea and dizziness. The combined effect caused him to fall hard on the pavement recently, ripping the top two layers of skin off most of his back. Buska is 32 years old — about the same age as the booming hard drug business in Malindi. But they soon realized that hooking the locals would be much more profitable in the long-run. Shee Omar shoots up while Ahmed Mohamed smokes a joint filled with heroin and marijuana in a back alley of Malindi. The shift marked a turning point for the HIV epidemic in Malindi. Shee Omar readies himself for injection as his friend, Ahmed Mohamed, prepares the dose of heroin. So this is better. In the back alley of a neighborhood called Sea Breeze — with the Islamic call to prayer echoing over the tin-roof houses — Omar sat on a heap of dried coral and listened to his friend, Ahmed Mohamed, explain the best way to shoot. Sharing used needles — and the blood that comes with it — is one of the fastest ways to spread HIV. The Kenyan government estimates that along the coast, people who inject drugs account for 17 percent of new infections. And while the HIV prevalence rate in the general population stands at 5. Public health officials warn that ignoring such startling figures will come at a price. After shooting up, many of these drug users return home for unprotected sex with their spouses — or they sell sex for drug money. The higher HIV rates then spill into the general population. Ahmed knows the cycle all too well. But one thing he does without fail these days is use clean needles for every new injection. The recently opened Watamu Drop-In Center helps addicts in Watamu and Malindi with basic health care, as well as services to make their drug habits safer. Before it opened, most of the 1, people who come here had nowhere to go for even basic medical care. And these people are very impatient. Here, addicts receive fast and friendly treatment for just about any illness, as well as counseling for their addiction and evidence-based education on how to make their drug use safer. Hajji Fadhil Mohammed, right, listens to Ludovick Tengia, describe the steps of safe injection. Though he rarely shares his own history with clients, Tengia speaks to them from a place of experience. He spent more than a decade shooting and smoking heroin. His family watched as his circle of friends dwindled — many to drug overdoses, some to HIV. They were convinced he would follow them to the grave. In , he made his way to a rehabilitation center in Malindi. But when administrators there met him at the gate, they discovered he was carrying some leftover drugs and they refused to let him in. So Tengia waited outside the facility long enough to convince them that he was serious — that they should change their minds. Three days later, they finally did. As a former addict himself, Ludovick Tengia, the addictions counselor at Watamu Drop-In Center, tries to mitigate some of the harm the drug users cause themselves. But the No. No excuses. Photo by Mia Collis. Before they leave, drug users like Mohammed pick up free needles and syringes directly from the Watamu Drop-In Center. The theory goes that drug users will find a way to shoot regardless, so they should at least do it safely and without spreading HIV in the process — either to each other or to their sexual partners. But many conservatives cringe at the idea of handing drug users a tool for getting high. The U. President George W. Children deserve a clear, unmixed message that there are right choices in life and wrong choices in life, that we are responsible for our actions, and that using drugs will destroy your life. Similarly, when the government of Kenya launched a series of pilot needle and syringe programs along its coast in , Muslim clerics demanded they end immediately. This goes against the Islamic teachings. It is forbidden. So nine years ago, Issa checked himself into a rehabilitation program, where he quit cold-turkey. Because if they do that, they will just use more. Recently, one of his friends stepped on one while walking through town and was rushed to the hospital for tests and treatment. Shosi Mohamed, the Omari Project drug rehabilitation and outreach program coordinator, was among leaders responsible for bringing the needle and syringe programs to the coast. Elsewhere in the world — in cities from Amsterdam to New York — long-term studies show that implementation of needle and syringe programming has led to dramatically lower HIV rates without any uptick in drug use. Do they really need to keep on injecting? Are they injecting properly? It makes people think more about their best options. And the best options for most people is not sharing needles, or stopping injection altogether. Take, for example, Hassan Abdul, who knows about the Omari Project through its needle and syringe services. When he missed a vein the other day and shot heroin directly into the tissue of his hand, he knew to come here for emergency treatment. Roughly 40 percent of injection drug users in Malindi have developed wounds from poor injection practices. One of them is Mbarak Salim. Before the Omari Project launched the needle and syringe program in , year-old Mbarak Salim used the same dirty needles so often they became dull. A bloody wound opened at his regular injection site, eventually spreading and becoming infected. He uses clean needles now, which reduces the risk that the abscess will grow. Omari Project paralegal Monica Wanja also meets with clients like Salim when they stop in for treatment. She tells them about their civil rights and advises that they can find legal support at the center should they get into trouble. She tells them that she was once so overcome by addiction that she resorted to injecting in her breasts and genitals because the veins everywhere else were too damaged. When she gave birth to a daughter, she breastfed with one-hand and injected with the other. She rummaged through hospital trash cans for used needles. She had sex with Italian tourists at night for drug money. And eventually, she contracted HIV. Monica Wanja, a recovering addict and a paralegal at the Omari Project, wipes away tears while describing her former life of drug abuse. When I am gone, you will have no one. It is you now that has to make the decision. The Omari Project Drug Rehabilitation Center sits several miles outside of the town of Malindi, far removed from many of the temptations the recovering addicts face in normal life. The gate is always open at the Omari Project Drug Rehabilitation Center, several miles outside of town. Those who check themselves in can leave at any time. But most find this a peaceful spot to heal — or at least try. They cook meals together and garden between counseling sessions and meditation. They care for baby goats and chickens. Fatima Lali Athman was once employed by the Omari Project as an outreach worker. She is now, once again, a patient. Fatima Lali Athman knows this piece of land well. She checked in here for treatment in , sobered up and became such a success story for the Omari Project that the rehabilitation center hired her as staff. But her husband — a recovering drug user himself — started into heroin again shortly after Fatima returned home. She tried to resist the urge but said the easy access and constant temptation became too much. When she started smoking again, she quickly lost control. Athman checked herself back in as a patient several months ago — a deep embarrassment for her and testament to the fragility of the recovery process. I stopped caring about everything. Traditional Swahili dhows sail in the Indian Ocean off the coast of Malindi. Drug use continues to thrive here. But disease rates seem to have leveled off, health officials say. And that in itself, most agree, is a reason to keep hoping for more. This photo essay was produced with the support of the International Center for Journalists. Support Provided By: Learn more. Monday, Oct The Latest. World Agents for Change. Health Long-Term Care. For Teachers Newshour Classroom. NewsHour Shop. About Feedback Funders Support Jobs. Close Menu. Yes Not now. By — Jason Kane Jason Kane. By — Victoria Fleischer Victoria Fleischer. Leave your feedback. Share on Facebook Share on Twitter. By — Victoria Fleischer Victoria Fleischer vlfleischer. Enter your email address Subscribe.

The rise of injecting drug use in east Africa: a case study from Kenya

Malindi buy Heroin

Official websites use. Share sensitive information only on official, secure websites. While relatively rare events, abrupt disruptions in heroin availability have a significant impact on morbidity and mortality risk among those who are heroin dependent. This qualitative analysis describes the shortage events and consequences from the perspective of heroin users, along with implications for health and other public sectors. As part of a rapid assessment, 66 key informant interviews and 15 focus groups among heroin users in Coast Province, Kenya were conducted. A qualitative thematic analysis was undertaken in Atlas. Overall, participant accounts were rooted in a theme of desperation and uncertainty, with emphasis on six sub-themes: 1 withdrawal and strategies for alleviating withdrawal, including use of medical intervention and other detoxification attempts; 2 challenges of dealing with unpredictable drug availability, cost, and purity; 3 changes in drug use patterns, and actions taken to procure heroin and other drugs; 4 modifications in drug user relationship dynamics and networks, including introduction of risky group-level injection practices; 5 family and community response; and 6 new challenges with the heroin market resurgence. The heroin shortage led to a series of consequences for drug users, including increased risk of morbidity, mortality and disenfranchisement at social and structural levels. Availability of evidence-based services for drug users and emergency preparedness plans could have mitigated this impact. Heroin shortages, characterized by an abrupt onset, are relatively rare events that create the potential for an increase in risk-taking behaviors; however, the impact on individual behavior remains understudied Degenhardt, Day, et al. Heroin droughts are associated with overdose due to decreasing tolerance or drug adulteration, polysubstance drug use, engagement in risky injection behavior, change in demand for drug treatment services, and an increase in criminal activities i. By making clean needles and syringes available, NSP decreases drug-related risk behaviors such as sharing of injection equipment Strathdee, The Kenyan shortage described here may be the first to be documented in a developing country. Kenya has been heavily impacted by a generalized heterosexually transmitted HIV epidemic, however while the HIV prevalence among adults in the general population is 5. Recent estimates indicate a large and growing population of injectors in coastal Kenya reporting high risk behaviors Kenya et al. Despite this high burden of HIV among heroin injectors, access to needle and syringe programs NSP and medication-assisted therapy MAT were publically unavailable at the time of the shortage. The heroin shortage in Coast Province, Kenya, which occurred between December and March , was precipitated a series of events that began with a speech by the former U. Ambassador to Kenya discussing drug trafficking, money laundering, use of drug profits by drug barons to influence political processes, particularly in the Coast Province Michael Ranneberger, November 16, The Kenyan Minister of Internal Security then named members of Parliament and a Mombasa businessman with suspected involvement in drug trafficking. Attention was drawn to this issue at the local level; demonstrations by local women's groups challenged the government to take action against drug barons supplying drugs to users. The sudden scarcity of heroin rapidly led to severe opioid withdrawal and demand for treatment by thousands of drug users Kitimo, Office of the Global AIDS Coordinator in carrying out an assessment to document to the consequences of the shortage and make recommendations for introducing evidence-based services for heroin users Njenga, In this paper, we report findings from this rapid assessment conducted in Coast Province, Kenya. We describe, from the perspective of heroin users: the landscape before, during, and after the shortage, including a actions taken to get drugs during the shortage and associated challenges, b changes in drug use patterns and types of drugs used during and after the shortage, and c injectionpracticesanddrug paraphernalia sharingthat increasedrisk for blood-borne diseases, including HIV. Findings are used to make recommendations for health and other public sectors in Kenya. The rapid assessment was carried out April—May Rapid assessment methodologies allow for quickly collecting locally relevant data, particularly with hard-to-reach and stigmatized groups. Rapid assessments are a relatively low cost method that engages the local community and target populations and makes recommendations based on local realities, which is useful in influencing policymakers. Like other qualitative methods, rapid assessments do not show magnitude, do not result in statistically significant results, and are generally only rapid in the collection, not analysis stage, as traditional coding practices are used. Field staff were recruited from the University of Nairobi-Manitoba and community-based service organizations CSO , which have a long-standing relationship with the target population. About 30 staff received a weeklong training on individual and group interviewing, recruitment, safety, and ethical issues and were divided into two-person interviewing teams to facilitate note taking and audio recording. A purposive sampling approach was used whereby CSO field staff used a verbal script to approach heroin users from drug-using communities where drug sales and use occurred. Sampling aimed at exploring a range of heroin user experiences of the heroin shortage, as opposed to sampling the population for empirical generalizations. Eligibility criteria included: at least 18 years of age, fluent in English or Kiswahili, resident of the Coast Province during the majority of the past two years, self-reported heroin or other opiate use smoked, inhaled, or injected at least once in the past year, and willing to take part in an audio recorded interview. Ethical approval was obtained from institutional review boards from the Kenyatta National Hospital and the U. Centers for Disease Control and Prevention. Before initiating data collection, all eligible persons underwent verbal informed consent procedures. Separate open-ended discussion guides, which were organized by several domains of inquiry, were used for KIIs and FGDs. The four overlapping domains of inquiry for this analysis focused on: drug use and acquisition, service demand and utilization, extent of community support, and recommendations for needed health services for heroin users. Since discussion guide questions were based on changes over the pre-shortage, shortage, and post-shortage periods, a visual aid was used to help participants refer to the different periods. Audio-recorded KIIs and FGDs were transcribed verbatim in the interview language Kiswahili and translated into English for computer-assisted qualitative analysis in Atlas. Analysis was undertaken by the first three authors. We extracted text from the complete transcripts for the four domains. All three analysts undertook multiple reads of these texts before developing a preliminary analysis codebook, which was based on an organizational system reflecting a priori themes investigated during the interviews Table 1. Next we determined probable situations linked to each of the broader thematic foci. Lastly, we identified the landscape environment likely to be associated conceptually with each one. After several careful readings of the extracted text by all three analysts, each analyst was assigned a domain one analyst was assigned two domains to independently mark and broadly code meaningful pieces of text. We re-sorted the data by these broad codes as well as the temporal sequence i. Reassignment of domains occurred and percent agreement assessed for paired text between analysts. As a final step to ensure overall consistent code application, the first author reviewed all coding and resolved any remaining coding discrepancies. In addition to triangulating data across interviewers, data triangulation was assessed across sites and modes of data collection. Given the rapid assessment design of our study, member check validation, whereby findings are presented to participants or community members to confirm the accuracy of the interpretations, was not undertaken. Understanding the various ways in which people experience and make sense of a phenomenon is emphasized. Analysis requires researchers be aware of and suspend their own preconceptions; interpretation occurs in an iterative manner. We then revised our original organizational system to better align with the emerging personal experiences and hearsay accounts i. Lastly, we examined the interrelationships between themes. Table 2 provides the revised thematic framework that emerged from our analysis. While the thematic foci remained the same, reconceptualization of the situational factors and landscape for some themes was required. Emphasis was primarily on dealing with a social, economic, and political landscape in which they were caused to question or become more mindful of: 1 heroin availability, cost and quality; 2 withdrawal and strategies for alleviating symptoms of withdrawal; 3 changes in drug use patterns, and actions taken to procure heroin and other drugs; 4 modifications in drug user relationship dynamics and networks, including introduction of risky group-level injection practices; 5 community response support by some and reproach by others ; and 6 new challenges emerging from the resurgence of heroin. Participants attributed the scarcity of heroin in the Coastal Province to increased law enforcement, which had caused drug barons and peddlers to retreat from the drug market. Participants frequently mentioned that during the shortage, available heroin was adulterated. Cement, chalk, powdered bleach, and other additives were mixed to cut the drug, thereby reducing the quality and posing risk to those who injected it. As indicated by a male KII from Bamburi, heroin was even adulterated with caffeine:. You can know because when you put it in a syringe it separates and it collects at the bottom. The starting point for descriptions of the unga heroin shortage began with personal and hearsay accounts of the painful symptoms of withdrawal and acute arosto cravings. Most participants gave descriptions of headaches, vomiting, diarrhea, body aches, and other painful physical reactions endured as a result of having to cut back or entirely stop using heroin. In some instances, participants spoke of the death of friends or acquaintances related to acute withdrawal. A male KII participant from Ukunda explained:. These had a lot of troubles. Some even got heart attacks and died. I know of six people who died. There is always feelings of fatigue, continued diarrhea, dehydration, loss of appetite and frequent visits to the toilet, plus sweating profusely. Across KIIs and FGDs, accounts of codeine as the primary drug treatment solution described limited and insufficient pharmacotherapy results. Additionally, healthcare worker demeanor toward heroin users, codeine dosing approaches, and changes in illicit drug-use patterns related to codeine treatment were also highlighted. While involuntary, transfer of heroin users to treatment by the authorities or sungu sungu religious leaders who take on the role of civil obedience monitoring was reported. Some participants observed a change in the way they were regarded by police, with a focus on health care over criminalization. Persons experiencing extreme withdrawal and related complications were reported to be admitted on an inpatient status. Others were provided medicine via outpatient services, including mobile distribution. Most participants indicated that the medicinal effects of the codeine effectively dulled the pain associated with withdrawal; however, insufficient dosage for pain management was also described. Some dispensing sites were said to follow a group patient dosing schedule, whereby patients would be dosed together at the same amount with dosing tapered over time. When a new patient presented for treatment, he was folded into the group and prescribed the same amount as his fellow patients. Participants explained that in such instances, a person did not receive dosage levels adequate for attenuating withdrawal pains and, therefore, continued using heroin. As explained by a male KII participant in Mtwapa, changes in mode of using heroin also occurred:. The only problem was that, when I went back for more of the medicine they refused to give me more so I moved from smoking the heroin and started injecting heroin because the heroin was scarce. If I found 2 or 3 doses, I would use that to inject myself. I never went back to the hospital. Participant stories of codeine detoxification were interwoven with accounts of being treated as if they were invisible and other unpleasant encounters with clinic staff. Invisibility-related stories centered on descriptions of nurses walking past a queue of users, and rather than providing consultation for care, the nurses took breaks or entirely ignored patients. Many participants indicated that this was a deterrent to treatment and they would leave before they were prescribed medicine. An overriding perception was that the nurses were unfamiliar with addiction. Heroin users described the nurses as not knowing how to treat their withdrawal symptoms and being unfamiliar with the physical and emotional toll that came from either withdrawal or injection practices e. Themes around changes in drug use related to drug treatment during the shortage ranged from completely stopping heroin use to a continued search for heroin despite recognizing that circumstances had forced them to use less heroin of poorer quality. Personal and hearsay accounts of users switching to smoking heroin mixed with cannabis a cocktail and using other drugs to relieve withdrawal symptoms were presented. A male KII from Ukanda described his own behavior during the shortage and what he noticed in others:. It was very challenging because heroin was not available. Some of them used \[homemade brew\] others used \[Rohipnol\], beer and tablets. During the shortage I was using \[marijuana\]. In a FGD from Kilifi, male participants describe using other drugs with the intent of achieving similar effects to what they got with heroin while suppressing withdrawal symptoms:. These are what helped us to get high. Most people used \[Rohipnol\] too because one of the biggest problems when you don't get the heroin is lack of sleep. The \[Rohipnol\] would help us deal with that problem. Some of the participants focused on how the diminishing drug quality or quantity necessitated shifting from smoking heroin toward injecting it to experience the steam high. A female KII participant from Kilifi stated:. It was like toffee. A few participants stated that during the shortage, the practice of injecting the blood of a user who had recently injected i. The blood could be shared with as many people as possible to help them reduce withdrawal symptoms. One male from Bamburi stated:. One person injects and when the steam has risen the friend who has arosto, gets blood from him and injects and gets better. The steam stays longer when injected, not like the cocktail which you will have to smoke again. Given the challenges that arose in accessing sufficient heroin, participants recounted the desperation that led users to take part in potentially dangerous and health compromising actions to get drugs. In some instances, the shortage drew users together and in others, competition and conflict arose. In situations where drug users relied on one another to access or buy heroin, risky injection practices emerged. A female FGD participant from Lamu recounted:. During the shortage, I shared because heroin was not accessible. After the shortage, I do not share because I do commercial sex and when they pay me, I inject myself. Joint actions to get heroin included users pooling their resources and coordinating travel to procure heroin that would be shared among a group. Users relied on rumors about where heroin could be purchased. Descriptions were provided of drug users traveling long distances within the coastal towns and as far away to Nairobi km from the Mombasan coast in search of heroin. A male KII participant from Ukunda said the following about his network's experience:. We used to go looking for it wherever it was found, even if it was in \[Nairob\]. You had to look for money, go and look for it and ensure that you buy it and use it. Because if you didn't use it, you felt as if you were suffering from malaria or typhoid. But sometimes you would go there to buy it and fail to get it because your friends might attack you and snatch your money. So you miss it. The sungu sungus were described as taking an oppositional stance toward drug use, appointing themselves as neighborhood police and physically attacking users caught stealing or injecting drugs. Some drug users indicated that they were more afraid of the sungu sungu than they were of the police. Participants described instances of drug users being lynched or set on fire. A female KII respondent from Baburi recalled:. By the time they decided to help her; by taking her to the hospital, it was serious, she didn't last. She died. In many instances, the police reportedly took on a referral role and began escorting people for treatment to health facilities, rather than arresting them. Participants indicated that the police practice of taking bribes from drug users decreased during the shortage. Participants described a change in law enforcement policy whereby drug sellers would be targeted for arrest and users would be directed, seemingly involuntarily, to hospitals. You would think that they were taking you to prison but that was not the case; they were taking us to hospital in order to be given medicine. They named individual organizations, described services offered, and mentioned that they accessed these services. Females seldom talked about services availability and access. One female from this same FGD group said:. KII and FGD participants indicated that following the resurgence of heroin, the cost, while not as low as before the shortage, decreased substantially and that drug purity was somewhat reestablished. In the absence of effective drug treatment programs, persons who had stopped using heroin faced a continued urge to use and eventually returned to using drugs as exemplified by a FGD participant from Kilifi:. Even after taking those medicines, you are just tempted to go out and smoke or sniff with friends. Even if you wanted to sleep after taking them, you cannot really sleep. Additionally, participants explained that peer pressure from other users, temptation from seeing others use, and idleness due to lack of employment contributed to relapse when heroin availability resurged. A male FGD participant from Likoni describes these factors related to relapse:. You may be arrested and taken to a rehab somewhere, and it is important that when we are released, we should be given some work to do. Because when you go back home, you will mix with your former friends. When you are idle you definitely relapse into using drugs. Narratives also focused on accounts of overdosing and death as drug availability resumed and purity improved. They indicated that when heroin became available again, the potential for overdose was thus elevated. A female KII participant from Mtwapa explains:. I know of one friend in Malindi, he died because he stopped and when he went to take the stuff it was strong and he put a lot in his syringe and shot himself and died. Participants explained that when the heroin drought ended, health facilities that had provided codeine at no patient cost started charging for it. Participants expressed that the fee was prohibitive for those who wanted to access this medication. Most of the persons interviewed indicated that they were unemployed and earned money through selling scrap and doing any odd jobs. Participants were inclined to use this money to buy drugs, not seek codeine, as the codeine only mildly relieved pain from withdrawals. When the heroin supply resumed, the quality improved, the price decreased, and selling points where heroin was previously available re-emerged. Without free access to withdrawal pain relief from codeine or methadone to curb cravings, many people returned to heroin use. Reports of overdose and death were reported. A female KII participant from Malindi stated:. The police relaxed, the community relaxed and everywhere you went, it was raining unga so the users had a field day and most of them died due to overdose. KII and FGD participants indicated that Kenyans in the Coast region primarily smoked heroin before the crisis, but given the lower quality of heroin, its increased costs, and diminished availability, users turned to injecting because it was a more effective high. Once the heroin supply resumed, and injection had become their preferred mode of administration, a new cohort of injection drug users emerged. A male KII from Mtwapa explained:. We provide first-hand accounts on the course and consequences of an abrupt heroin shortage from the perspective of heroin users themselves. Reports of heroin shortages typically rely on quantitative data, aggregated at the state or national level, to describe changes in drug use, consequences of drug use, and demand for treatment Degenhardt, Day, et al. These accounts, mostly from Australia, conclude that shortages result in an overall improvement in the drug use situation after a period of both positive and negative effects related to risky drug use, morbidity, and service use among drug users. This is likely because they occur in favorable contexts where injection is the primary method of heroin administration and harm reduction interventions are accessible Degenhardt, Hall, et al. Despite the GoKs quick response to provide emergency treatment services during the heroin shortage, the consequences on drug users were unanticipated and severe as health facilities were not able to address the health crisis experienced. In his review of Australia's shortage, Jaffe cautioned the effects of abrupt changes to the heroin supply in places where smoking and inhalation are the primary modes of heroin use Jaffe, Our findings validate this concern. Unlike the shortage in Australia, we found that injection increased as users transitioned from smoking to injection of heroin during the shortage to compensate for the low quality and quantity. Participants noted injection behavior and equipment sharing continued after the shortage ended. In the absence of MAT in Kenya, the heroin shortage may have contributed to the number of heroin users who underwent morbidity associated with acute withdrawal, drug substitution, using tainted heroin, or overdosing. Deaths resulting from acute withdrawal are extremely rare and while they were reported by participants, they were likely the result of overdose following a period of withdrawal. Additionally, heroin users may have also experienced heightened risk for HIV infection and other blood-borne pathogens. The availability of evidenced-based HIV prevention strategies like NSP and MAT could have mitigated exposure to risks, prevented the switch to injecting behavior, treated opioid dependence among users experiencing withdrawal and reduced demand for drugs. These strategies could have also reduced overdose and death. Participants attributed heroin-related deaths during the shortage to withdrawal and use of adulterated heroin as opposed to overdoses. Overdose deaths were usually described as occurring in the context of the resurgence of heroin into the market. Anecdotally, the research team learned from partnering CSOs that drug shortages occur with some frequency, usually aligned with public holidays due to people returning home to visit their families. Although such seasonal disruption may not have the impact caused by the Kenyan shortage, public health infrastructure and readiness plans should nonetheless be instituted to adequately respond to and minimize the morbidity and mortality experienced as a result of sudden heroin unavailability. Drug users reported disenfranchisement during and after the shortage through forced treatment, inadequate care and violence by law enforcement, health care providers and community leaders who were operating without standard protocols. People who use drugs experience disproportionately low access to and use of health and other social services. While not a direct consequence of the shortage, drug users referred to this public resentment in the context of the shortage. Negative experiences during the shortage may have led to further marginalization of drug users from health and social services. Implementation of these evidence-based interventions along with recommendations outlined below should be considered in contexts with precipitating factors described here: emerging heroin epidemics, absence of prevention and response systems for drug uses, and non-injection as primary administration mode. The effects of the Kenyan shortage should be used as a catalyst to inform a comprehensive response and emergency preparedness strategy. In health facilities, providers and clinical management staff could be trained on treating opioid addiction, acute opioid withdrawal, and human-rights based treatment of patients. From an emergency response perspective, the Ministry of Health could develop a protocol for supply chain systems for providing appropriate pain relief medication, forecasting stocks for adequate dosing and re-hydrating provisions when necessary. Engaging police and community leaders on issues and actions related to people who use drugs is also recommended. This includes psycho-social counseling, patient exit plan counseling to include long-term addiction treatment placement, and appropriate medical referrals relevant to heroin users. In particular, the referral system would benefit from needle and syringe distribution networks to ensure users that switch to injection can prevent HIV and hepatitis C transmission. Additionally, police and community members should be provided with information on risk reduction including safer drug-using behavior and safeguards to prevent overdose once heroin returns. Changes in police policy may have been helpful during the shortage, but direction to treatment facilities should be voluntary in nature. A response system should also acknowledge the authoritative role of community sungu sungu and religious leaders in the community and work to prevent physical or emotional violence towards drug users. We note that reliability of interviewing persons retrospectively about changes in drug supply, patterns of drug use, and service uptake may be questionable given the time lag between the shortage and interview to determine changes. Our sample may not represent the range of heroin users in coastal Kenya and the absence of data collection on demographic other than sex and behavioral information for FGD participants does not permit us to explore the for potential differences in experiences and perspectives based on such factors. Generalization of our findings is neither appropriate nor feasible. Similar to qualitative methodology in general, team-based rapid assessments methodology is very much influenced by the researcher. Despite establishing canons for collecting and analyzing these qualitative data, our findings may be influenced by our own interpretations and biases. In conclusion, the abrupt change in heroin availability in Kenya had important implications on mobility and mortality of drug users. An emergency preparedness plan that includes health, law enforcement and civil society sectors is urgently needed. This study was supported by the following collaborators: Dr. Frank Njenga, Dr. Reychad Abdool, Mr. Earnest Munyi, Dr. Mumbi Machera, Ms. Emma Mwamburi, Dr. Doug Bruce, Dr. Jessie Mwambo, Dr. Barrot Lambdin, Dr. This study and publication was made possible by support from the U. SM and GM performed the analysis with strong support from EML in conceptualizing the findings and writing the first draft. All authors provided substantial revisions to the manuscript and approved the final version. The authors declare that they have no non-financial competing interests. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention and the Government of Kenya. As a library, NLM provides access to scientific literature. Int J Drug Policy. Published in final edited form as: Int J Drug Policy. Find articles by Sasha Mital. Find articles by Gillian Miles. Find articles by Eleanor McLellan-Lemal. Find articles by Mercy Muthui. Find articles by Richard Needle. Issue date Apr. PMC Copyright notice. The publisher's version of this article is available at Int J Drug Policy. Pre-analysis organizing system for Kenya heroin shortage rapid assessment, Open in a new tab. Post-analysis organizing system for Kenya heroin shortage rapid assessment, 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. Heroin market disruption: precipitating factors. Actions by heroin users to deal with the situation. Disruption in drug users patterns: desperate and actions taken. Pain, desperation and uncertainty set the stage. Disruption in drug users patterns: desperation and actions taken. Social behavior: positive or negative peer pressure.

Malindi buy Heroin