in Colombia: Prevalence, Demographics and Risk Correlates. David Toro Tobón, MD., Dedsy Y. Berbesi Fernández. Ph.D.,Pedro Mateu-Gelabert, Ph.D, Ãngela ...
Drug Dealing Among People Who Inject Drugs in Colombia: Prevalence, Demographics and Risk Correlates.
FACULTAD DE ENFERMERÍA
David Toro Tobón, MD., Dedsy Y. Berbesi Fernández. Ph.D.,Pedro Mateu-Gelabert, Ph.D, Ángela Segura-Cardona, Ph.D., Liliana patricia Montoya Velez.
Introduction Over the past decades, injecting drug use has been recognized as a global public health issue1. Reports estimate that globally, close to 16 million people inject drugs2. While Colombia has been historically considered as drug producer3, injectable drug use in the country has increased rapidly over the past decades4. However, studies assessing drug injection practices among people who inject drugs (PWID) in Colombia are limited and policy design, and implementation has been sluggish and ineffective. Previous studies report a prevalence of drug-dealing PWID to range between 17% and 43%5. Studies on the influence and implications of drug markets and exposure to microtrafficking on PWID strongly suggest that PWID get involved in drug dealing in order to provide for their own drug consumption6. Furthermore, drug-dealing PWID are characterized by sociodemographic vulnerabilities, risky environments7, as well as a complex network of social and altruistic relationships specific to each drug market6. To date, few studies have described the characteristics and risky injection behavior of drug-dealing PWID. Studies indicate that drug-dealing PWID are more likely to engage in injection risks such as higher injection frequency8, sharing of syringes and other injection paraphernalia9, assisted injection, and overdose5. Additionally, behaviors and implications on associated injection risks and secondary harms are influenced by demographic, social, cultural, and economic network factors such as prior criminal involvement, social exclusion, lack of income generating activities, chronic poverty, unstable housing, lack of autonomy and alternative exciting activities, and the unique illicit drug scene of each population10. While PWID in Colombia are highly exposed to drug market and drug-dealing networks11, a correlation between PWID and drug-dealing involvement has not been described. Therefore, the aim of this study is to analyze the demographics and injection practices of drug-dealing PWID in five Colombian cities.
Methods A cross-sectional study was conducted in five Colombian cities (Armenia, Bogota, Cucuta, Medellin and Pereira) in 2014. A total sample of 1.099 PWID were recruited through Respondent-Driven sampling. A minimum sample size of 184 PWID for each of the selected cities was calculated using the formula for the proportion with a 1–α = 95% confidence level, a 3.5% error and a design effect of 2.
Results Number of participants 300 250 200 150 100 50 0
265 193
rm
ia n e
A
Bo
á t go
210
c ú C
Statistical analysis was conducted in SPSS 21.0. Correlates of demographic characteristics, drug dealing involvement and injection behaviours with the dependent variable (Having sold drug or being part of a drug dealing operation over the previous six months) were examined through a binary logistic regression model and multivariate analysis. The analysis was based on chi square and Fisher’s exact test with their odds ratios and 95% CI. All tests were two-tailed and used p = 0.05 as the cutoff for statistical significance.
60 50 40 30 20 10 0
250 205
ín l l e
d e M
Involvement in drug dealing Yes No OR CI 95% A CI 95% (%) (%) OR
Median injection network member size
a r i e r Pe
55 37
5
ia n e
rm
A
á t go
Bo
18
10
a t u
c ú C
ín l l e
d e M
Socio demographic characteristic Age Mean Median Minimum Maximum
a r i e r Pe
n
%
26 25 18 59
85.9 13.5 0.1
Socioeconomic status (SES) Low Middle High
745 338 37
66.3 30.1 3.3
Education Primary school (initiated or completed) Secondary school initiated or completed) University (Initiated or completed) None
98 747 259 10
8.7 66.5 23.1 0.9
Low socioeconomic OR status AOR Drug-dealing or Illegal activity as primary income source
0R AOR
1-3
63.2
52.8
1.0
Obtained new syringes or needless from a drug dealer
Yes
8.5
2.9
3.5 1.0-12.4 3.3
No
91.5
97.1
1.0
Gave or sold used syringe
Yes
53.4
41.3
1.6 1.2-2.0 1.4
No
46.6
58.7
1.0
1.0
1.4 1.1-1.8
1.4
1.0
1.0
Shared syringes
4
1.2 1.07 3.0 3.2
5
6
1.2-1.9
1.3
1.0–1.7
1.0 0.7–15.8
1.0 1.0–1.9
1.0–1.8
Shared paraphernalia Injected another person Self-paid for injected drug
7
8
OR
3
4
6
7
8
1.29 1.0
AOR
2.1
OR 1.2
AOR 0.6
0R
0.6
AOR
1.6
Discussion PWID in Colombia have high exposure to drug market and drug-dealing networks11, and our data strongly suggest a relationship between injectable drug use and drug dealing involvement. In our study, 56% of participants had been involved in drug dealing during the previous six months. Importantly, it has been described how drug dealing represents financial, social, and altruist benefits to PWID6,8. Moreover, the main reason for PWID’ s involvement in drug dealing is to sustain their own consumption, make economic profit, and improve their accessibility to drugs 6, 9, 12, 13. Interestingly, this study found a negative correlation between drug dealing and paying for drugs participants injected. This result could be explained by the usual dynamic of a trading day, in which drug dealers purchase large amounts of drugs and divide it in personal doses for further retail, saving the remaining for self-consumption6. Also, our results might be due to the finding that drug dealers provide their labor and skills in exchange for drugs to be self-injected 14. This study found that drug-dealing PWID had higher daily injecting frequency, higher risk of overdose and of giving or selling used syringes to other people. These results are consistent with previous reports in which PWID involvement in drug dealing was associated with high individual and network behavioral risks such as blood-borne infection transmission, overdose, seeking injection assistance, lending syringes and having higher injecting frequency 5, 8. Our results indicate that the risk of having injection equipment confiscated by the police, obtaining new syringes or needles from a drug dealer and of giving or selling used syringes was greater in drug-dealing PWID. These findings could be a consequence of high police interaction, distributive needle sharing, and limited access to new needles and syringes due to law enforcement based policies 15, 16. Our observations may serve as a starting point for subsequent qualitative studies and policy-making efforts addressing the complex economic, social and cultural factors leading to drug dealing by PWID. In addition to law enforcement actions, further design and implementation of structural and personalized policies is required to decrease drug dealing involvement as well as increase harm reduction and consumption prevention strategies for drug-dealing PWID and their consumption networks 17, 18.
References
1.5
0
0.5
1
1.5 1.4
OR
1.4
AOR
Has ever known 0R someone who died from drug AOR overdose
5
1.4
0R
Injection related-harms:
Has ever suffered heroin or opium overdose
2 2.5
Used encapsulated 0R drug or ready for injection vial AOR
3
1
AOR
Sociodemographic
2
1.5
0
PARTICIPANTS SOLD DRUG OR WERE PART OF A DRUG SELLING OPERATION ON THE PREVIOUS SIX MONTHS.
1
36,8
Injection risk behaviours during last injection episode:
965 152 1
0
47.2
Injection equipment Yes 62.0 53.5 was confiscated by police or by any No 38.0 46.5 other authority
Gender Male Female Transsexual
56%
>4
Daily injection rate
Background socio-demographic characteristics of the sample
An adapted version of the Behaviours of High Risk Drug Consumers Survey (CODAR by its Spanish acronym) was administered to each participant. This study was approved by CES University’s ethics committee, participant's information confidentiality was guaranteed and interviewers were trained to reduce potential information bias.
a t u
Injection risk behaviours during previous six months:
1.5 1.2
2
2.5
1. Majid Ezzati et al. Global and Regional Burden of Disease Attributable to Selected Major Risk Factors, 2004. 2. Mathers et al. The Lancet, 2008. 3. UNODC Colombia. Colombia: Monitoreo de Cultivos de COCA 2015. 4. Colombian Ministry of Justice and Law. El problema de las drogas en Colombia: Acciones y resultados 2011-2013. 5. Kerr et al. Journal of Psychoactive Drugs, 2008. 6. Dwyer et al. International Journal of Drug Policy, 2010. 7. Werb, D. et al. The American Journal of Drug and Alcohol Abuse, 2008. 8. Sherman et al. Journal of Urban, 2002. 9. DeBeck et al. Drug and Alcohol Dependence, 2007. 10. Kerr et al. Social Science & Medicine, 2009. 11. Alvarado, L. Microtrafico y narcomenudeo: caracterizacion del problema de las drogas en pequeñas cantidades en Colombia, 2013. 12. Deering et al. Drug & Alcohol Dependence, 2011. 13. Small et al. International Journal of Drug Policy, 2013. 14. Alvarado, L. Colombian Ministry of Justice and Law, 2013. 15. Benson et al. Applied Economics, 1992. 16. Kerr, T. et al. International Journal of Drug Policy, 2005. 17. Richard H., International Journal of Drug Policy, 2005. 18. Robles, R. et al. Journal of Substance, 2004.
