In Montenegro, new synthetic drugs are sold under a different name, so a person is often mistaken that they are consuming some substance they know," he says to Center for Investigative Journalism of Montenegro (CIN-CG) a guy who has been in the process of recovering from drug use for several years, and now he is actively fighting this problem and trying to help the community.
According to him, new psychoactive substances (NPS) are not coming to Montenegro for now, but they are there. These are drugs whose chemical composition has been changed, so that they mimic the effects of those whose use is illegal, such as heroin, cocaine, marijuana... People who use drugs (OCD) may be exposed to a greater risk of adverse health outcomes due to new substances. Due to the sometimes unconscious consumption of substances with higher potency or a mixture of substances, the consequences can be dangerous - poisoning and death.
And yet, NPS can become a serious problem, if the state does not recognize the danger and does not introduce measures in relation to the consequences that may occur if this issue remains unresolved. [MM1] The world black market of drugs is developing and changing, and the expansion of these substances was also due to the decision of the authorities in Kabul in 2022 to drastically reduce poppy production in Afghanistan. In addition, the war in Ukraine, as stated in the World Drug Report (WDR) for 2023, which is done by the United Nations Office on Drugs and Crime (UNODC), disrupted the routes of heroin and cocaine trafficking.
According to an earlier UNODC study, Afghanistan produced up to 2020 percent of the world's opium in 85, supplying about 25 million people who use drugs globally, which is 80 percent of all those who use heroin and other opiates.
As most of the heroin consumed in Europe came from the opium poppy grown in Afghanistan, Europe, experts warn, must be prepared for the possible consequences of banning the cultivation of opium poppy and the expansion of new substances.
"The previous short-term ban on opium production in Afghanistan led to a shortage of heroin in Europe, which in some countries was associated with long-term changes in opioid consumption patterns," a psychologist at the Institute for Public Health of Montenegro (IJZ) told CIN-CG. Tatiana Đurišić.
These new drugs, Đurišić points out, are a global problem. Legislation, registries, support systems, as well as international control are not effective enough to follow the trends, so some new psychoactive substances are legally produced and used in numerous countries.
Montenegro is still struggling with old problems and there are currently no mechanisms by which the use of new drugs can be first detected and then regulated.
A new psychoactive substance appears on the market almost every week, according to the UNODC's annual world drug reports. In 2021, 52 new drugs were reported for the first time through the European Early Warning System (EWS), and the total number of NPS monitored by the European Monitoring Center for Drugs and Addictive Diseases (EMCDDA) was 880.
One of the possible consequences of the lack of availability of heroin, Đurišić also states, could be an increase in the demand for synthetic opioids, as well as the demand for treatment of opioid-related problems.
More than 60 percent of patients receiving opioid agonist therapy are now 40 or older, Đurišić also states, while less than 10 percent are younger than 30 years old. "This means that the services must respond to a complex set of health care needs in a population that is becoming more and more vulnerable," Đurišić points out.
Drugs that are not officially registered have been used in Montenegro for years, because only the Forensic Center can analyze the composition of substances and until it announces that a new substance has been found in the analysis, it officially does not exist in Montenegro. CIN-CG wrote about this problem. A urine drug test in our country can show the presence of about 10 substances - marijuana, benzodiazepines, amphetamines, methylenedioxymethamphetamine, barbiturates, methamphetamine, methadone, cocaine, opiates, tricyclic antidepressants. New substances cannot be detected in this way in our country, so the delusion that someone does not use drugs can be maintained.
"Fortunately, Montenegro is not yet a country where these substances are available in large quantities, but they occasionally appear on the market. In order for a country to be 'ready' for the arrival of the NPS, it must have a fully developed and efficient system of early recognition and warning, which includes all those organizations and institutions that operate in this area, i.e. high-quality and timely inter-institutional cooperation and communication", he says for CIN-CG Marija Mijović from the NGO Juventas, which for years has been providing services to people who use drugs through the Direct Support Program for people at risk of social exclusion and the socially excluded.
According to her, this system exists in Montenegro, but it is not functional enough. "It aims to alert all involved subjects when an NPS comes to us in order to adequately respond, adjust the services provided, as well as the information provided directly to people who use drugs, as well as to the general public. This is not the case in Montenegro".
Mijović warns that it must be worked on, "since the NPS are present in the states of the region, so it is a matter of time when some of them can come to Montenegro."
Until the publication of this text, CIN-CG did not manage to get answers from the Ministry of Health to numerous questions related to this problem.
NPS is a significant public health challenge
Đurišić warns that new psychoactive substances are also a global challenge for public health. "There are more and more synthetic drugs, new substances and manufacturing practices are appearing on the drug market, and many of the harmful effects of drug use are exacerbated by drug interactions that are knowingly or unknowingly consumed together. The market today is characterized by the availability of a wider range of drugs, which are often of a high degree of potency or purity".
Europe, as she also points out, is still an important production area for some substances, especially synthetic drugs and cannabis. "Consumers are exposed to a greater number of psychoactive substances and, among other things, new synthetic drugs for which knowledge about the health risks is often limited."
Montenegro does not keep statistics on the number of deaths due to overdose. CIN-CG also wrote about it. In the last month alone, according to data from the NGO Juventas, at least four people have died from overdoses. Accurate data would be important for understanding the scale of the problem and for establishing better support systems.
Đurišić also states that there are indications that the availability and production of synthetic cathinones is increasing in Europe. These are substitutes for drugs such as amphetamine and MDMA. These cathinones are increasingly available in this part of the world and could play an increasing role in the market.
And the current drug problems in North America are an example of how changes in the availability and use of opioids can have dire consequences. Potent fentanyl derivatives have largely supplanted prescription opioids and heroin as the leading cause of the opioid-related death epidemic.
Montenegro, Mijović points out, is a country located on the transit route of drug trafficking, and substances such as heroin and cocaine are extremely common. "There may be an influx of other substances into the drug market, such as synthetic drugs, which could potentially be more available, more potent and could be found at a more favorable price compared to what is currently available on the market. This means that the services provided should be adapted to the market situation and the needs of people who use drugs," she says.
More and more diverse and dangerous cannabis products
A small amount of new drugs is often enough to prepare a large number of common doses. This may increase the risk of poisoning.
Đurišić says that cannabis products are becoming increasingly diverse on the European continent, as well as that new synthetic cannabinoids are continuously being discovered in plant material. They look like natural cannabis and can be falsely sold as cannabis to unsuspecting consumers.
"Certain synthetic cannabinoids are extremely potent and are associated with fatal or non-fatal overdoses," says Đurišić.
Diversity in the cannabis market increased further in May 2022 when the first semi-synthetic cannabinoid, hexahydrocannabinol (HHC), was found to be available in Europe. HHC is chemically similar to cannabis and has mostly identical effects. However, neither the pharmacology nor the toxicology of HHC have been thoroughly investigated in humans. During 2022, HHC was sold as a “legal” alternative to cannabis, in e-cigarettes and food products.
"After its appearance, other semi-synthetic cannabinoids were discovered, which points to the fact that there is commercial interest in that area. The novelty of these forms of cannabis and the lack of empirical evidence mean that there is considerable uncertainty regarding the possible effect of these substances on health," warns Đurišić.
The last national strategy for the fight against drugs was made a decade ago
And while all this is happening, Montenegro still does not have a new National Strategy for the fight against drugs. The last one was done in 2013.
In relation to the time when the previous strategy was written, Mijović points out that there is progress when it comes to the coordination of competent institutions and the civil sector, but that it is certainly not yet at a satisfactory level. "There are no mechanisms or procedures that are binding, and a good part of communication comes down to personal acquaintances and the activities of dedicated individuals in this area. The future strategy should certainly contain certain recommendations on the development of protocols, certain mechanisms and procedures of action, so that at the systemic level, coordination among subjects in the field of drug policy could be more easily established and be expedient".
The strategy provided for the provision of conditions for further education in the field of addiction and rehabilitation, as well as capacity building for experts who work in the field of treatment of people who use drugs, at all levels of health and social care.
The strategy also stated that the tasks of the selected doctor in the treatment of OCD should be defined in detail and professional protocols should be developed at the level of primary health care.
Mijović points out that, according to the knowledge of NGO Juventas, such protocols do not exist. "Persons who use drugs even perceive that they experience the greatest degree of stigma within the health system, as shown by our earlier research. This idea requires the establishment of a clear standardized system of work and protocols, as well as the improvement of knowledge within primary health care about working with people who use drugs".
However, although Montenegro is late in following trends, Đurišić believes that it is a favorable circumstance that our country has the opportunity to learn from the experiences of other countries that, unfortunately, have already faced this problem.
People who use drugs are rarely a priority for decision makers
In the National Strategy for the fight against drugs for the period from 2013 to 2020, it is stated that the capacities for establishing a register and reporting system on drugs should be strengthened. The register has been established, but the data are not comprehensive and do not represent the real situation in the country, says Mijović.
According to data from the Register, in 2022, the first request for treatment for opioid addiction was made by 76 people, five for cannabis, and three for cocaine. Previously, there were 79 people in treatment for opioid use, and one each for cocaine and cannabis. There were no persons who presented for the first time for treatment from other stimulants, hypnotics and sedatives, hallucinogens and volatile substances. The highest number of those who presented themselves for opioid treatment for the first time in the period from 2016 to 2022 was in 2020 – 198 of them.
These data do not reflect the real situation, nor can conclusions be drawn about drug use trends in Montenegro based on them.
Đurišić, who is also the head of the Registry, explains that the number of registered treatment seekers is low from year to year, which does not correspond to reality.
People who use drugs are rarely a priority for decision makers in our country, says Mijović.
"It is necessary to strengthen the availability of services and services, especially in rural areas where the degree of stigma is higher, provide better access to services for women who use drugs and create conditions for the introduction of services and support services for young people who use drugs. Especially for minors for whom services are currently lacking..."
The list of steps to improve the position of people who use drugs is long, and state institutions, due to everything that is happening in the drug market in Montenegro, but also in the world, would have to wake up and understand the seriousness of the problem, so that we do not face the challenges that they bring unprepared emergence of new substances.
Necessary changes in the management of the Registry
The process of managing and functioning of the Drug Registry, says Đurišić, proved to be very challenging for several reasons.
Among the most significant are insufficient awareness of the legal obligation to send applications to the register by most data providers (new staff in health care institutions are not informed about the legal obligation to report to the Register by the competent authorities), the lack of clear and effective control mechanisms and the application of legal consequences in cases of non-compliance these obligations, as well as the impossibility of identifying all requests for treatment in the reporting year (most often, health institutions will send the client's application form, if they send it at all, only once, without mandatory updating of the application in the new calendar year).
In addition to these, there is also the problem of outdated registry software and related legislation, unsatisfactory quality of submitted applications in a certain number of cases, as well as significant overloading of certain centers and doctors participating in the treatment of people who use drugs (ODD), especially those in institutions, which are also the biggest sources of data.
Difficulties are also represented by the fact that the register currently covers only public health institutions. In addition, many patients are not willing to be registered in the registry. In addition to still being a reason for great discrimination, drug use is also an activity punishable by law.
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