Research paper
Heroin shortage in Coastal Kenya: A rapid assessment and qualitative analysis of heroin users’ experiences

https://doi.org/10.1016/j.drugpo.2015.08.010Get rights and content

Highlights

  • A rapid assessment of an abrupt heroin shortage in Coast Province, Kenya was conducted.

  • Rooted in storylines of desperation, drug users describe consequences of the shortage.

  • Changes in drug use, morbidity, treatment demand, and relationships are documented.

  • Evidence-based services and preparedness plans could have lowered the impact.

Abstract

Introduction

While relatively rare events, abrupt disruptions in heroin availability have a significant impact on morbidity and mortality risk among those who are heroin dependent. A heroin shortage occurred in Coast Province, Kenya from December 2010 to March 2011. This qualitative analysis describes the shortage events and consequences from the perspective of heroin users, along with implications for health and other public sectors.

Methods

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.ti. to identify salient themes related to the shortage.

Results

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.

Conclusions

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.

Introduction

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 et al., 2005b, Degenhardt et al., 2004, Jaffe, 2005). Heroin droughts are associated with overdose due to decreasing tolerance or drug adulteration, poly-substance drug use, engagement in risky injection behavior, change in demand for drug treatment services, and an increase in criminal activities (i.e. theft, violence; Gibson et al., 2005, Weatherburn et al., 2001).

The availability of comprehensive HIV prevention programs, including needle and syringe programs (NSP) and medication-assisted therapy with methadone (MAT), along with a supportive harm reduction policy environment are important in the context of heroin shortages (PEPFAR, 2010, WHO, 2013). MAT is effective in treating heroin dependence thereby reducing associated risks including Hepatitis C, HIV and death (Amato et al., 2004, Gowing et al., 2004). By making clean needles and syringes available, NSP decreases drug-related risk behaviors such as sharing of injection equipment (Strathdee, 2001).

Heroin shortages have been reported in the United States during World War II and the early 1970s (Agar, 1978, Schneider, 2008), Australia in 2001 (Degenhardt et al., 2004, Degenhardt et al., 2002), and England in 2010 (Hallam, 2011, Simonson and Daly, 2011). The Kenyan shortage described here may be the first to be documented in a developing country. Kenya faces an emerging HIV epidemic among injection drug users (Kenya et al., 2011, Kurth et al., 2015). Both heroin smoking and inhaling have been documented in Kenya since the 1980s (Beckerleg, Telfer, & Sadiq, 2006). Heroin trafficking from Pakistan and Iran to East Africa is well established and seaports in Mombasa, in coastal Kenya, are vulnerable to drug trafficking (UNODC, 2012). Kenya has been heavily impacted by a generalized heterosexually transmitted HIV epidemic, however while the HIV prevalence among adults in the general population is 5.6%, over 20% of injectors on the coast are infected with HIV (Kurth et al., 2015, Lyerla et al., 2012). Recent estimates indicate a large and growing population of injectors in coastal Kenya reporting high risk behaviors (Kenya et al., 2011). 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 2010 and March 2011, was precipitated a series of events that began with a speech by the former U.S. 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, 2010). 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 subsequent arrests, mostly of low-level drug dealers and peddlers, pushed higher-level suppliers underground to reduce the possibility of arrest, which in turn reduced the supply of heroin to users (Githongo and Wainaina, 2011, Munyi, 2011). The sudden scarcity of heroin rapidly led to severe opioid withdrawal and demand for treatment by thousands of drug users (Kitimo, 2010). Following the onset of the shortage, the chairman of Kenya's National Campaign Against Drug Abuse requested assistance from the U.S. 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, 2011).

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) injection practices and drug paraphernalia sharing that increased risk for blood-borne diseases, including HIV. Findings are used to make recommendations for health and other public sectors in Kenya.

Section snippets

Methods

The rapid assessment was carried out April–May 2012. 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

Results

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. Overall, participants’ accounts of the shortage were rooted around desperation and uncertainty. 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

Discussion and conclusions

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 et al., 2005b, Weatherburn et al., 2001). These accounts, mostly from Australia, conclude that shortages result in an overall improvement in the drug use

Role of funding source

This study and publication was made possible by support from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) through cooperative agreement 3U2GPS002846 from the U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV/AIDS (DGHA).

Contributors

SM, GM, MM and RN designed and implemented the study. 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.

Conflict of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. 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.

Acknowledgements

This study was supported by the following collaborators: Dr. Frank Njenga, Dr. Reychad Abdool, Mr. Earnest Munyi, Dr. Mumbi Machera, Ms. Emma Mwamburi, Dr. R. Doug Bruce, Dr. Jessie Mwambo, Dr. Barrot Lambdin, Dr. Sheryl McCurdy and the following local community-based service organizations: REACHOUT Kenya, Omari Project, and Nairobi Outreach Services Trust.

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