Epidemic in Macedonia
(Return to Table of Contents)
In the early 1990s use of heroin has grown into epidemic proportions
in Macedonia. There are presently an estimated 5000 to
6000 heroin users on a total population of two million
citizens. The number of heroin users is expected to grow over
the coming years to three to four times the current size of the
population. Heroin use seems to have emerged in all ethnic
groups, but may be more widespread among Albanians. Among
ethnic Macedonians heroin use seems largely concentrated among
15 to 25 years olds, while in the Albanian community its use may
have spread to all age groups. While reportedly mainly an urban
phenomenon, some informants believe that heroin is also used among
rural (Albanian) populations in the west of Macedonia.
Only a minority of heroin users inject. Most users snort, smoke
the drug in cigarettes, or chase it from aluminum foil. Drug injecting
is an important risk factor for HIV infection. The fieldwork suggests
that the level of HIV risk behaviors among injecting drug
users (IDUs) is unacceptably high. This suggestion is
corroborated by the 100% hepatitis C seroprevalence in a small
treatment sample. Likewise, knowledge about the virus and safer
drug use skills are very limited; among IDUs as well as among
treatment providers. HIV is not on the agenda of treatment agencies
in any meaningful way.
At present, HIV seroprevalence among treatment populations is
zero. This merely indicates that HIV has not yet been introduced
into the networks of IDUs in Macedonia. This should not be taken
as a reassurance, because, when introduced, the virus could spread
like wildfire. However, through rapid and aggressive implementation
of a "Harm Reduction" based HIV prevention campaign
aimed at IDUs, it may be possible to contain an HIV epidemic in
There is a need for epidemiological and ethnographic research
to collect necessary information about: the nature and prevalence
of the use of different drugs; which groups are using drugs (in
terms of e.g. ethnicity and subcultural orientation); HIV prevalence
in out-of-treatment populations; nature and extent of HIV risk
Drug treatment, drug education, and HIV prevention services aimed
at drug users have either not been developed or are in their infancy.
Knowledge and experience of treatment providers is limited and
overemphasize psychopathology. The demand for drug treatment is
expected to grow rapidly. In order to meet the rising
demand for drug treatment, it is advised to involve primary health
care providers in the treatment and care for drug addicts and
to reconsider the current barriers (e.g. methadone prescription
regulations) that complicate their involvement.
A comprehensive drug policy is presently absent in Macedonia.
We recommend to develop a drug policy based on the following
Public Health objectives: 1. Management of the current heroin
epidemic, and 2. Prevention of a large scale drug related HIV
epidemic. It will be impossible to eradicate the use
of heroin and the heroin epidemic will certainly grow. However,
it is possible to manage and contain the heroin epidemic and to
limit its negative consequences --of which an HIV epidemic is
the gravest-- through the implementation of a pragmatic "Harm
Such a policy concentrates on the provision of "low threshold"
treatment and other practical services to drug users, whereas
law enforcement interventions are secondary to Public Health goals.
They are generally restricted to high level organized drug trafficking.
Drug use, possession of small quantities and consumer level exchanges
are not an enforcement priority, except where it results in nuisance
for other people.
One must not forget that the young people who are getting
involved with drugs are the children of Macedonia. They are the
country's future. The question must be posed whether
to criminalize these children (with all the negative consequences,
ranging from imprisonment and social stigma to AIDS and other
grave health consequences), or to help them through this difficult
period. We believe the latter to be the obvious choice.
The Open Society Institute can contribute to the development of
an effective response to the drug problem in Macedonia in various
- Use its influence to establish a pragmatic Public Health oriented
drug policy in Macedonia, based on scientific research and respect
for human rights.
- Help to raise the level of knowledge and skills of all professionals
who are dealing with drugs and drug users. This can be pursued
through the following examples:
- Providing a reader of translated state-of-the-art articles
on different drugs, epidemiology, ethnography, drug policy, HIV/AIDS,
harm reduction, human rights, treatment and prevention, etc.;
- Making the information on drug use and AIDS issues that is
available on the internet/World Wide Web accessible through the
establishment of local dial-in connections;
- Organize trainings locally with international harm reduction
- Sponsor conference visits and internships at innovative harm
reduction projects elsewhere (the latter in particular when starting
up new harm reduction projects.
- Support the establishment of an outreach project, which would
offer needle exchange and other HIV prevention services, low threshold
medical care and social support, while simultaneously collecting
systematic information on the nature and extent of drug use and
HIV risk behaviors.
- Support the Center on Treatment and Prevention of Drug Abuse
in moving to a more central location in Skopje and in involving
the primary health care system in the treatment of drug problems.
- Support the development of a credible drug information campaign
aimed at young adolescents.
(Return to Table of Contents)
There are several indications that in the first half of the 1990s
the prevalence of drug use has risen sharply in the Republic of
Macedonia. While there is little reliable scientific data on the
phenomenon, increasing police seizures for instance, rising numbers
of applications for treatment, media coverage and other anecdotal
information have induced serious concerns among many individuals
and organizations. The Open Society Institute Macedonia (OSI-M)
is among them and has initiated a program, "The Macedonia
Drug Initiative" (MDI), to help develop adequate responses.
The first problem MDI encountered is the absence of even the most
basic insight in nature and extent of drug use and drug related
problems. Likewise, the institutional responses that have been
developed so far have often, while well intended, been only partially
In particular the absence of specialized knowledge and experience
in addressing drug problems have motivated OSI-M to request for
assistance and expertise from the umbrella organization, the Open
Society Institute New York (OSI-NY). Within OSI-NY issues around
illicit drugs have recently become a priority, inspiring the establishment
of The Lindesmith Center (TLC), a drug policy and research center,
headed by Dr. Ethan Nadelmann. For that reason OSI-M's request
has been relegated to TLC, which appointed Dr. Jean-Paul C. Grund,
Research Fellow in Residence at TLC, and Dr. Dusan Nolimal of
the Institute of Public Health of Slovenia to make a first assessment
of the Macedonian situation regarding the use of illicit drugs,
related problems and the availability and quality of treatment
modalities, and to provide both OSI-M and the New York office
with recommendations for further action.
(Return to Table of Contents)
Meetings with key officials
The information in this report was collected during a fact-finding
mission to Macedonia from March 6 to 16, 1995, carried out by
Jean Paul Grund and Dusan Nolimal. During this visit a series
of interviews and discussions with representatives of key governmental
and non-governmental institutions and individuals knowledgeable
about drug-related issues in Macedonia were held. Gathering information
on the nature of drug use in Macedonia, problems caused by their
use, affected populations, and the available or potential resources
and control measures that can be brought to bear on these problems
was the first task undertaken.
Several knowledgeable individuals were identified prior to arrival
in Macedonia. Some of them suggested other people with whom to
talk. All were interviewed to learn what they believe to be the
major drug problems and what short-term and long-term approaches
could be developed. Notes were taken of each conversation.
A review of documents
Existing documents directly or indirectly related to drugs were
reviewed. Some general information on health was available at
National Institute of Public Health, more specific information
on drug treatment demands was available at psychiatric centers.
Information on drugs seizures and drug offenders was available
at the Narcotics Department of the State Ministry of Interior.
These documents provided information on the public and professional
awareness and concern about drug use and various health, social
and legal problems, as well as about individuals and organizations
responding to drug problems.
A questionnaire on new drugs and drug patterns, developed by the
National Institute of Public Health of Slovenia, was administered
to a number of key individuals to enhance the quality of the information.
The topics the questionnaire explored are: Which drugs or drug
taking habits are considered new in your country? What is at present
your main source of information about the emergence of new drugs
or drug-taking habits? What are the main advantages or disadvantages
of these sources of information? What are the practical results
of this information? Is there any statistical information on drug
use and users? Which other expert(s) in your country would you
advise us to contact for more detailed information on these matters?
Are there any prevention or intervention projects with regard
to new drugs in your country?
(Return to Table of Contents)
An important objective of the visit was to collect first hand
information on the local drug scene of Skopje --which is believed
to be the country's "drug capital"-- to complement the
information from "official" spokespersons. Because the
visit was limited to only 10 days in total, it was decided that
ethnographic fieldwork methods would be utilized to obtain information
on the extent to which use of various drugs occurs, the types
of users and use patterns, the availability of drugs in different
local settings, risk behaviors for HIV, etc..
The ethnographic methodology relies on establishing contacts and
developing a level of trust with certain key individuals who are
knowledgeable about the field under study and are respected by
their peers. In addition to contributing information about themselves
and their own experiences, those "key informants" provide
quick and smooth access to people and places that would otherwise
take considerably more time to explore. The main data collection
tools used in this ethnographic "mini study" have been
"participant observation" and "informal interviews."
Applied in the field of drug use, the information generated by
ethnographic methodologies provides essential insights into the
characteristics and functioning of drug markets, drug consumption
patterns, user groups and motivations for use. Ethnography is
an especially valuable method when dealing with new, rather unexplored
issues. As Lambert and Wiebel (1990) explained, "[e]thnographic
research methods are appropriate for topics about which little
is known, primarily because ethnography is by its nature fundamental
and exploratory, preparing the way for more rigorous studies that
strive for precision and quantification. ... Ethnography serve[s]
to fill knowledge gaps and set[s] the groundwork for further scientific
inquiry. ... It is at this exploratory, descriptive stage of research
that ethnographic and qualitative methods can make significant
contributions to the knowledge and understanding of problems"
(Lambert & Wiebel 1990).
The fieldwork in Skopje went surprisingly well. Some of our discussion
partners (e.g. at the Narcotics Department of the State Ministry
of Interior) supplied us with some names of bars and clubs where
they thought that drugs were being used and sold. Thus, a first
objective of the fieldwork became to check out the assumption
that drugs are used and sold in the entertainment circuit. Early
in the visit we were introduced to a young (+/- 20 years) person
with extensive knowledge of Skopje's drug scene and of the bars
and clubs where the Macedonian youth gather and socialize. This
turned out to be an essential contact, who guided me (Dr. Grund)
through Skopje's entertainment circles and introduced me to many
(ex-) users of heroin, marihuana and other drugs. During these
nightly field trips nine (coffee) bars and clubs were visited
which, according to my field contacts, represented the most popular
hang-outs of Skopje's youth. In the night of Saturday March 11
I visited a "Techno Rave" where I contacted the DJ,
Goran Putica, who is the editor of "Channel 103 Free Radio
Skopje," the local independent radio station. This station
plays eclectic and alternative music and caters to a largely young
and western oriented audience. The station is actively promoting
discussion on drug use and has broadcasted pro marihuana and anti
heroin messages. Being an important participant in, and observer
of, Skopje's youth culture, Mr. Putica provided an expert opinion
on several key issues and another entry into the scene of Skopje.
The information generated by these combined methodologies has
been compiled and will be presented according to topic in the
following chapters. Appendix 1. provides an
overview of the persons and organizations contacted during the
(Return to Table of Contents)
It needs to be stressed that the information gathered in this
report provides only an initial assessment of the drug use situation
in Macedonia. Largely because of the limited time available, many
issues could only be addressed superficially. In addition, structured
data collection on drug use and drug related problems in Macedonia
is almost absent. Therefore, to a large extent the researchers
had to distill an understanding of the situation from anecdotal
information, impressions, opinions and incomplete statistics.
In this situation the ethnographic fieldwork not only functioned
to gather first hand information, but also to check some of the
information collected during the meetings with official spokespeople.
Thus, while the preliminary character of the report must be emphasized,
the combination of approaches has resulted in an informed conception
of drug use, drug related problems and the institutional responses,
which can serve as a basis for further development of research,
policy, professional training, and services for those who have
come into problems with the use of drugs.
(Return to Table of Contents)
Macedonia is one of the countries established after the collapse
of the Socialist Federal Republic of Yugoslavia and one of the
youngest independent states in south-eastern Europe, with 2073
thousand inhabitants in 1993. The majority of inhabitants are
Macedonians, about 23 % are ethnic Albanians and some are ethnic
Turks (3.8%), Romanies (2.6%) and Serbs (2.1%). The proportion
of ethnic Albanians in the population is considerable in the municipalities
of Tetovo (71%), Gostivar (63%), Kicevo (46%) and some other cities.
The highest percentage of ethnic Turks live in Brod ( 31%). The
concentration of ethnic Serbs is highest in Kumanovo. The Constitution
of the Republic of Macedonia guarantees the freedom of religious
expression and the Macedonian orthodox church and the Islamic
religious community are the largest religious structures. The
official language of the country is Macedonian which is written
in the Cyrillic alphabet. Albanian, Turkish and Serbo-Croatian
are also taught in many schools. Also, newspapers and media programs
are available in the languages of the minorities. According to
the Macedonian Constitution, the language and alphabet of minorities
are used officially in the units of local self-government, with
considerable proportions of minority inhabitants. Nevertheless,
recent disturbances around the establishment of an Albanian language
university in Tetovo show that these rights are not automatic.
The level of health care in the country is being slowly improved
in cooperation with the World Health Organization and other international
organizations. The WHO health care policy and strategy "Health
for All" has been introduced as part of the health care policy
of the country and the developing policy includes an emphasis
on prevention and primary health care, as well as the promotion
of healthy life styles and a healthy environment. Important changes
in the health care system have been introduced, including private
enterprise in treatment, care and pharmacy activities. This privatization
process has attracted considerable attention over the past four
years. The level and improvements in the health care standards
of the population can be observed by the following indicators:
The total number of physicians in the country increased from 873
in 1961 to 4.487 in 1991. The life expectancy in Macedonia increased
from about 55 years for both sexes in the mid-1950s to over 74
for women and 70 for men in 1990. The natural infant mortality
rate is still very high compared to the Western Europe, but was
reduced from 45.9 per 1000 live births in 1986 to 34.5 in 1990
and 24.1 in 1993. The birth rate (live births per 1000) has fallen
from 18.7 in 1986 to 15.6 in 1993. The country is also faced with
an absolute decrease in number of births from 38.234 in 1986,
to 35.401 in 1990 and 32.374 in 1993. The mortality rate (deaths
per 100.000 population) has been moving between 686.9 (in 1990)
to 752.1 (in 1993) in the period 1986 - 1993. The main causes
of death in both sexes in 1993 were diseases of heart and circulatory
system, and cancers.
An estimated 1.314.000 inhabitants are considered part of the
"able-to-work" population in 1994. About 948.000 persons
are "active" and the number of employed individuals
was estimated to be 458.000 in 1994. 117.151 persons were seeking
employment in 1980 compared to 174.848 in 1993. The unemployment
rate is rising. In 1994 a social welfare program envisaged a transfer
of welfare funds to about 45.000 households including 180.000
inhabitants. In 1992, 6.000 households were covered under this
(Return to Table of Contents)
The use of illegal drugs in Macedonia dates back to at least 1969,
when the first cases of drug addiction became visible to the authorities.
Before 1969 use of drugs or drug trafficking were almost absent
in the caseloads of the police and courts. Between 1945 and 1980
only 40 cases were brought for Macedonia's criminal courts. Between
1980 and 1990 the courts heard an average of 5 to 10 cases per
year. After 1990 +/- 100 cases came to the attention of the courts
and especially after 1992 a strong increase was experienced. Law
enforcement data for the period of 1979 to 1983 show 40 cases
of illegal drug trafficking with 60 perpetrators. In comparison,
for the period of 1990 to 1994 these numbers are 231 cases with
419 offenders. Table 1 provides an overview of these cases.
Table 1. Discovered criminal acts,
offenders and seized quantities of drugs, Macedonia, 1990 - 1994.
||Criminal Acts||Seized Quantities of Drugs in KG
Clearly, the number of cases and involved offenders have increased
considerably and the almost five-fold increase in the latter period
predicts a continuing growth --a trend anticipated by local law
enforcement authorities. The major feature of the 1990 - 1994
statistics is the increase in the quantity of heroin seized. Though
cocaine has been reported to be increasingly available on the
illicit market, only in 1990 the drug was confiscated. According
to the police most of the seized marihuana was domestically grown.
As it concerns all infractions of article 245 (unauthorized production
of, and/or trafficking in, psychoactive drugs) of the Penal Code
of the Republic of Macedonia, the data presented in table 1 do
not distinguish between users, dealers or dealing users. However,
Mr. Stojanovski from the Narcotics Department of the Ministry
of Interior explained that about 40% involves recidivist, professional
drug traffickers, partly involved in international organizations.
Most of the offenders are between 25 and 30 years of age. Both
Macedonians and Albanians are among the arrested, as are a number
of foreigners (Turks). The number of Albanians is disproportionately
high in comparison with their representation in the population.
Table 1 suggests that opium, marihuana and especially heroin are
the main drugs on Macedonia's illicit market. The Republic of
Macedonia is renowned for its legal production of high quality
poppy plants. The harvested opium is processed into morphine and
other opiates for the pharmaceutical industry by "Alkaloid,"
a pharmaceutical company in Skopje. However, not all harvested
opium ends up in this state controlled industry; the traditional
poppy farmers often keep some aside for their own stock, which
is used for medicinal or recreational purposes. According to several
informants, raw opium has been stockpiled for many years. Over
the years an unknown proportion of this opium was diverted into
illicit channels, supplying a rather small group of users. Opium
was smoked, ingested (poppy tea) and, to a lesser degree, injected.
"Compote" (a home brew of several opium alkaloids, including
heroin) has only been observed incidentally. On a small scale,
raw opium can still be found on the illicit market as the result
of old stocks in the houses of the traditional producers. However,
the rising availability of cheap, high quality heroin has pushed
opium to the margins of the market.
Climatological conditions in Macedonia are favorable for the cultivation
of Cannabis and the plant grows in many parts of the country.
According to police sources the production of marihuana is increasing
--generally grown for personal consumption or distribution among
friends. The fieldwork provides the following picture of marihuana
use: Marihuana is probably the most widely used illegal drug and
the drug has a high level of acceptance among (westernized) youth.
A matchbox full of the locally grown product sells for about 10
"Deutsch Mark" (DM, the German mark is the financial
standard). All the marihuana encountered during the fieldwork
was from Macedonia and of poor quality. Both police sources and
cannabis users contacted in the field contended that marihuana
is usually sold through friendship networks; a sophisticated marihuana
trafficking industry is absent. Not only is the available marihuana
of limited quality, frequently it is hard to find. Several fieldwork
respondents complained about its unstable availability and compared
it to the relatively small effort it takes to buy heroin. As one
of them explained: "Often you cannot get grass, but 14 and
15 year olds have easy access to heroin."
Heroin has become increasingly available since 1990. While reliable
statistical data are absent, all the information available indicates
that a considerable and growing number of people are involved
in heroin use. All consulted parties consider heroin a major concern.
In the following chapters we will discuss several aspects of heroin
use in detail.
Cocaine has not been detected by the police since 1990. However,
several fieldwork respondents have either used cocaine themselves
or know people who have used it. But it is not easy to buy cocaine
and it is expensive (150-250 DM per gram). Some of the heroin
users interviewed have self-prepared cocaine base and smoked the
drug --a technique they learned while working in Germany. Amphetamines
do not seem to play a significant role in Macedonia's drug markets.
Psychedelics, such as LSD and Ecstasy (MDMA) are only sporadically
available. While treatment providers associate their consumption
with "the heaviest drug users," in fact, we found a
considerable interest in these drugs among the young, westernized
adolescents. Availability and use of these drugs may well rise
as they are often associated with the rave culture, which has
emerged in Skopje only very recently. According to one field respondent,
who had used both LSD and Ecstasy while traveling abroad, "you
can only get these drugs when a friend brings them along when
returning from a trip to Europe." He continued: "That
we cannot buy them here, is probably because they (the local dealers)
haven't realized their value yet." Inhalation of solvents
or glue does not seem to be an issue of importance in Macedonia.
Several psychoactive medications which in western Europe would
require a prescription, can be purchased in many (private) Macedonian
pharmacies without one. Some pharmacies sell Heptanon (methadone)
without a prescription, which is illegal. But, according to some
fieldwork respondents, a variety of analgesics, tranquilizers
and sleeping tablets, such as Mogadon, Carson, Flormidal, Diazepam
(Auparin), Prazine, Trodon, Lexilium and Phenobarbital can be
bought fairly easily, several of these even in their injectable
form. Many "junkies" reportedly experiment with a wide
variety of pharmacy drugs to either substitute or boost heroin
(Return to Table of Contents)
Reliable data on the number of drug users in Macedonia are absent.
Household or school surveys into the use of drugs have not been
conducted. Likewise, data on drug-related emergency room admissions
or drug-related deaths (e.g. reported by medical examiners) are
not available. Therefore, estimating the extent of drug use is
a precarious endeavor. The little information available comes
from the two psychiatric hospitals that offer treatment for drug
addiction, the State Penitentiary in Skopje, a register at the
ministry of interior and a 1994 WHO country survey.
Until 1990, about 600 individuals applied for drug treatment to
Bardovci hospital in Skopje. Yearly, 20 to 25 previously unknown
people were admitted to the hospital. In the period 1989 - 1993
Bardovci treated 181 drug addicts; 150 of them in the out-patient
Center for Treatment and Prevention of Drug Abuse. In March 1995
80 - 90 people were in treatment at the out-patient center and
an additional 14 were treated in the hospital. In 40% of cases
it concerned new patients. 95% of patients were between 15 and
25 years old. Prof. Dr. Jordan Jovev, director of Bardovci estimates
that there are currently 1400 "heavy drug users" in
Skopje, 300 in Kumanovo and 300 in Ohrid. 90% of them are heroin
The Neuropsychiatric department of the Medical center in Ohrid
admitted 40 patients for treatment of drug problems during the
past two years (1993 & 1994). Ages were between 19 and 21
years. Only 5 of these patients had been treated before. Dr. Sotiroski,
the psychiatrist in charge of drug treatment, reports that at
the end of 1994 there were 200 "registered drug addicts"
in Ohrid on a population of 75,000 people.
On any given day, the State Penitentiary in Skopje houses 20 to
30 drug addicts between the ages of 18 and 38 years, but according
to the prison doctor, Mihael Levenski, young people are in the
majority and on the increase.
A national register of drug users was set up in 1971. Both treatment
and law enforcement sources contribute to this register, which
includes individuals who are or have been in treatment and offenders
who are known drug consumers. By March 1995 about 850 individuals
were included in this register. Whereas between 1972 and 1990
the number of newly registered drug users varied from 25 to 30
annually, after 1990 a strong increase was experienced: 50 new
persons were registered in 1991 and 390 in 1994. Mr. Trpe Stojanovski,
statistical analyst at the Narcotics Department of the State Ministry
of Interior explains that the age of the new entries is decreasing
and that the "dark number" (the total population of
drug users) is much larger.
Finally, a 1994 WHO country survey mentions that "the total
number of drug users is above 6210." This number is extrapolated
by multiplying the number of known cases (621) --based on the
national register-- by ten.
In addition to these institutional "guestimates," a
number of heroin users (all males) were asked how many other heroin
users they knew personally. A 26 years old Albanian chaser said
he knows 40 other users personally. A 19 years old Macedonian
injection drug user (IDU) knew "about 50" other users.
A 32 year old Macedonian IDU knew "more than 60" other
users. A 20 years old Albanian dealer knew "at least 100"
others. His friend and colleague, a 21 years old Albanian said
he knew 200 other users. He continued by telling in German that
10 other junkies live in his street. On asking, he answers that
in total about 100 people live in his street which is located
in the old Albanian quarter of Skopje. A 28 years old Macedonian
IDU said "In my telephone book I have 40 junkies, so you
understand how many I know." All these users agreed that
heroin use has increased tremendously in the past five years --they
all started using within this period-- and that the drug is popular
among the youth. They all foresee a continuing increase in the
number of users.
Except for the state register data, these figures are all estimates.
In addition, these information sources all have their own specific
limitations. Because of the considerable time between the moment
people start using heroin and the first treatment contacts, treatment
data generally reflect a situation of two to three years back
in time. Treatment may furthermore not be very attractive to drug
users, or only to certain categories of drug users. For example,
it may not be attractive to Albanians (see table 2.). The state
register has been built up from 1971. Since then, several people
may have stopped using or died. The register also does not differentiate
between a marihuana smoker and a heroin addict. Likewise, it is
not very likely that prison records reflect the larger population
of drug users. In particular new and younger users are not very
likely to be incarcerated. Finally, the estimates of the heroin
users are highly anecdotal. However, the cited sources provide
us with a number of rather different perspectives on the same
issue. Therefore, put together, these figures may not
give us a reliable estimate of the number of drug users, but they
do indicate that the use of drugs has been increasing substantially
over the last few years and this trend is likely to continue.
(Return to Table of Contents)
Our interviews with treatment providers from Bardovci (both the
in-patient facility at the psychiatric hospital and the out-patient
center) in Skopje and from the Medical Center in Ohrid provided
some information on the people for whom the use of drugs has become
a problem. In both agencies patient data is hand recorded in patient
files and not arranged in a systematic and accessible format.
Therefore, a one page questionnaire was used to generate an estimated
overview of patient characteristics. Table 2. presents these estimates.
Table 2. Characteristics of Drug Users
in Treatment in Skopje and Ohrid, March 1995.
N = +/- 90
|Medical Center, Ohrid|
N = +/- 40
|Age ||15 £ "95%"
||19 £ "most patients" £ 20
|Ethnicity ||90% Macedonian;
|80% Macedonian, rest Albanian, Turkish and foreign
|Living Arrangements ||50% with
20% with friends or partner
|"most" with parents/family
|Employment Status ||"almost
||"mostly" unemployed |
|Primary Drug ||Heroin
|Secondary Drug ||Cannabis / Opium
|Usual Mode of
|50% Chasing, 50% IDU ||50% Chasing, 50% IDU
|IDU Past Month ||60-65%
|Age 1st Heroin Use ||14 - 15
||15 - 17 |
|Duration Regular/Daily Use
||7 months - 2 years ||3 years
|Previously Treated ||60%
|HIV Antibody Prevalence ||0
(Return to Table of Contents)
This chapter provided a first look at drug use in Macedonia. While
one can, and should, have certain reservations concerning the
validity of each piece of information, when the pieces are put
together a picture starts emerging of the drug problem in Macedonia.
Since 1990, the amount of heroin seized by the police more than
tripled. In the same period the number of drug users known to
the authorities increased greatly and a growing number of people
applied for help with a drug problem, the drug being heroin. The
age of those applying for help is decreasing, a phenomenon also
observed in the state register and among those incarcerated. It
becomes clear that a substantial number of young people in Macedonia
have gotten involved with heroin. In the next chapter we will
take a closer look at heroin.
(Return to Table of Contents)
For many years the former Yugoslav republic has been an important
transshipment country on the so-called "Balkan Route,"
which brings heroin produced in south-west Asia to western Europe.
The collapse of communism and the conflicts in the former Yugoslav
republic have all contributed to the re-routing and proliferation
of the Balkan route. An important branch now runs from Bulgaria
through Macedonia to Albania, from where it is shipped by boat
to south Italy. Another branch runs from Macedonia into Kosovo
and Northwards. However, the early 1990s have shown a considerable
spillover from these shipments into local distribution channels,
resulting in the abundant availability of high quality heroin.
(Return to Table of Contents)
Several of our discussion partners emphasized the importance of
the social determinants of the expansion in drug use in Macedonia.
The collapse of the Yugoslav Republic has resulted in the breakdown
of traditional societal structures. The current transition towards
a democratic society has lead to the devaluation of traditional
institutions and values, while developing new ones is a burdensome
task, fraught with new, previously unanticipated problems. The
introduction of a free economy has not been equally beneficial
to all Macedonians and, in combination with a more general economic
decline, the economic blockades and the return of migrant workers,
it has resulted in a high unemployment rate (30%) and a lack of
economic perspective for many young people.
Conversations with young people during the fieldwork confirm this
view. Many young Macedonians feel betrayed by the older generation,
who, in their opinion, have made a mess of the country. They see
little economic opportunities, even those who have jobs or are
still in school. At the same time they are very interested in,
and oriented toward, western culture and experience the current
socio-political situation as a barrier to reaching their goals.
A recurrent theme in these conversations was the unstable political
future of the country and the threat of ethnic conflict or war.
In one group of friends of mixed ethnicity (Macedonians, Serbs
and Turks) this was a particular concern. They sketched the horrors
of the Bosnian conflict and asked rhetorically "will I have
to fight my friends when the politicians mess up?" Some of
the young people spoken with even wondered whether Macedonia would
still exist as a separate entity in a few years.
The resulting mindset is a mixture of insecurity and indifference,
expressing itself in a dismissal of the established societal structures
and hedonistic experimentation. As the philosopher Wittgenstein
once said of the medieval plagues, "as the suicides increased,
so did the waltzing." Use of drugs, and heroin especially,
fits well in that mindset, as heroin provides the user with a
chemical sense of security, well-being and belonging.
Thus, in the early 1990s we can witness a situation in
Macedonia in which the presence of abundant supplies of high quality
heroin coincides with a mindset among the youth conducive to the
use of this drug.
(Return to Table of Contents)
The use of heroin has first become visible in Skopje, Macedonia's
capital. More recently it has become apparent in other, smaller
cities, such as Ohrid and Kumanovo. Dr. Jovev of Bardovci hospital
estimates about 300 users in both cities. According to one field
respondent heroin use started in Kumanovo one to one and a half
years ago and is on the increase. The Medical Center in Ohrid
started experiencing a rise in treatment applications for drug
problems about two years ago. Heroin use, and drug use in general
is generally viewed as an urban phenomenon. However, according
to Dr. Klekovski of the Macedonian Center for International Cooperation
(MCIC) in Skopje this is an incomplete picture. MCIC is conducting
developmental aid programs in several Albanian settlings in western
Macedonia. They have found that many of the families in the villages
in the areas of Debar, Gostivar and Tetovo are involved in trafficking
and/or use of heroin. "No single family is without use or
smuggling." Within the time frame of the study visit it was
not possible to research this account, but it seems certainly
worthwhile to follow up on this lead.
(Return to Table of Contents)
Heroin users come from various socio-economic and ethnic backgrounds.
The drug treatment centers seem to be primarily in contact with
young male users from ethnic Macedonian families with relatively
affluent social and economic positions. Information from police,
prison and treatment centers suggests that, although ages range
from 15 to 45 years, heroin users are becoming increasingly younger.
Users in treatment often live with their parents. Relatively few
women apply for drug treatment or get into problems with the police
(see table 2.).
The fieldwork corroborated this picture to some extent. All fieldwork
respondents were male. During the tours of Skopje's night life
only a few female heroin users were pointed out. Although all
respondents knew some, they believed female users were not common.
Respondents thought that women are much less inclined to use heroin
or drugs in general. However, young women do socialize with male
users. As one respondent explained: "When I was 17-18, it
was very hip to have a junkie boyfriend." Most users were
in their early twenties and these younger users were initiated
into use of heroin when they were 15 to 17 years old. Many felt
that heroin users are starting at increasingly younger ages: "...
14 to 15 year olds have easy access to heroin." On the other
hand, some of the respondents knew a number of older users of
Albanian ethnicity. In fact, they suggested that many of the Albanian
families involved in consumption level dealing were using their
merchandise themselves, from the 18 year old son, to the grandfather
and grandmother: "Where do you find whole families on heroin?
... In Macedonia, in Ghazi Baba!"
Another, related, point of interest is that there may exist different
pathways into heroin use for Macedonian and Albanian users. Macedonians
more often seem to start using during adolescence within a context
of experimentation among friends and, perhaps, rebellion against
parental and social order. In contrast, Albanians may have been
involved in heroin selling prior to initiating its use. Heroin
use may than be initiated as a response to the stress of dealing
or simply because many friends and relatives are also using the
drug. One Albanian business man in his thirties (not a drug dealer)
explained his heroin use in terms of "just getting through
the day," increasing work performance and lowering general
Risto is a 19 years old Macedonian from relatively affluent family. His father owns part of a factory. Risto
is still in school and wants to study abroad after his graduation. His father is willing to pay for his studies
abroad, as he currently doing for Risto's car, clothes and spending money. Risto started to use heroin when
he was 16 and has been using for three and a half years now. He started to smoke the drug in cigarettes,
sniffed it and chased for a long time. More recently he initiated injecting. When he started using, Risto was
hanging out with his friends who were dealing. In the beginning he did not pay or only little money for the
heroin. His friends shared their drugs generously. For Risto heroin use is very much a social experience.
With a group of friends he would pool money and than he would buy the drugs, because of his good
connections. When the drugs were bought, they would go to the apartment of one of the group members to
use and relax, or sometimes, when an
apartment was not available, they would use in an elevator or in a car. Currently Risto is clean. He stopped
using about 4 months ago. He went into Bardovci, but walked out after ten days, because his treatment
consisted of little more than a bed and drugs were all around in the hospital. Since he left the hospital he
has used once. However, as he is taking Naltrexone, an opium antagonist, he did not feel any effect of the
(Return to Table of Contents)
Several of our discussion partners were under the impression that
heroin and marihuana are sold and (sometimes openly) used in certain
bars and clubs. This assumption has been investigated during the
When drugs are sold in bars and clubs, transactions generally
do not find place in the center of the venue, but in the more
remote, less well lighted and transient areas, such as hallways
and restrooms. The restrooms are also the place where illegal
(powder) drugs are ingested. Often this leads to small groups
hanging out in and around the restroom area.
In all the bars and clubs that were patronized, a visit was paid
to the restroom and other remote areas where drug activity might
be expected. Garbage in trashcans and on the floor was inspected.
No indications of drug use or drug dealing were found. At the
Techno Rave I visited, I made several rounds through the venue
in search of drug activity. Again, nothing indicated the presence
of drug dealing. The restroom area was not a hang-out. After the
party ended I searched the floor, but did not find any drug related
I discussed the issue of drug use and dealing in bars and clubs
with several field respondents and they provided a rather unanimous
view with regards to both drug use and drug dealing: Drugs are
not used in the bars and clubs, an important reason being fear
of undercover police or police informers. If people use drugs
when they go out, they do so just before entering the club, for
example, they may smoke a "joint" (a marihuana cigarette)
in the car in the parking lot. Likewise, drugs are generally not
sold in the bars and clubs they and their peers frequent. Marihuana
selling is rather loosely organized within friendship networks.
When available, drugs such as Ecstasy or LSD also find their way
from one friend to another.
Mr. Stojanovski of the Narcotics Department of the Ministry of
Interior contended that all ethnic groups are involved in drug
trafficking, although Albanians are overrepresented in comparison
with their proportion in the population. From the accounts of
the fieldwork respondents it becomes clear that consumption level
heroin dealing is almost exclusively in the hands of Albanians.
Sometimes Macedonian users work for Albanian dealers or buy in
bulk (on consignment) and distribute the drug among their using
friends. Apparently only few Macedonians are trusted enough to
be able to do so. Two of the Albanian respondents (ages 20 and
21 years) were dealing.
In Skopje, heroin sales are to a large degree localized in one
Albanian neighborhood, Ghazi Baba. Many of the people living in
Ghazi Baba are apparently involved in the heroin trade. The early
evening (between 5 and 10 p.m.) is the busiest period. Most transactions
are conducted in the street: the buyer requests a certain quantity
(minimum 0.25 or 0.5 gram) and hands the money to a runner, who
subsequently goes into one of the houses and returns with the
drug. Only well known and trusted (Albanian) customers are allowed
inside. Heroin can also be purchased in many of the Albanian teahouses,
but often these only sell to Albanian users. The average price
of a gram of heroin is DM 70.-, but when buying in bulk or when
having "good contacts" the price may go down. Sometimes
users drive across the Bulgarian border to buy heroin in some
quantity for DM 25 - 30 per gram.
(Return to Table of Contents)
For many people, heroin is automatically associated with injecting
drug use. Injecting paraphernalia --needles and syringes, spoons
and tourniquets-- have become strong symbols for this psychoactive
drug. In fact, globally speaking, this association is only valid
for a minority of heroin users. Heroin, and most other opiates,
can be taken into the body in other, although less efficient,
ways. Simple oral ingestion (mixed with food or drink or not),
snorting and smoking all produce similar states of intoxication.
Injecting is only one of several routes of heroin self-administration,
yet the most direct and efficient. Globally, heroin injectors
are outnumbered by those who ingest this drug by method of smoking
or, more correctly, vapor inhalation.
The most common form of heroin smoking is called "chasing
the dragon," or abbreviated, "chasing." Sometimes,
for example in the Netherlands, it is called "chinesing,"
revealing its Eastern origins. When chasing, the user puts some
heroin powder on an oblong piece of aluminum foil and heats the
powder drug from underneath. The drug melts and vaporizes and
the vapors are inhaled through a tube held between the lips.
Heroin users in Macedonia administer the drug in various ways.
They may inject the drug --under the skin (subcutaneously), in
a muscle (intramuscularly), or in the vein (intravenously). The
latter seems to be the norm among Macedonian IDUs, while the former
two may signify a transition stage from non-parenteral administration
modes towards injecting. Another mode is to chase the drug from
aluminum foil, known locally as "puenje na foliji,"
or by the English term "chinesing." The use of the latter
term is rather peculiar, as it originates in the Netherlands.
Heroin is also smoked in specially prepared cigarettes. In addition,
some people use the drug intranasally (snorting), which is somewhat
odd, as the heroin available in Macedonia is the brown heroin
base and not well suited to nasal inhalation. This type of heroin
is designed for smoking. It has a low melting point, but does
not dissolve easily in water (or in the mucous membranes of the
nose). For this reason, IDUs add an acidifier (e.g. lemon juice
or ascorbic powder) to the heroin, when preparing a shot.
Among the users in treatment 50% usually inject their heroin and
the other half utilize various non-injection administration modes.
However, discussions with fieldwork respondents suggest that among
out-of-treatment users the prevalence of injecting may well be
much lower. Whether this is really the case should be the object
of systematic research, but several observations support this
hypothesis: On average, the heroin sold in Skopje is of rather
high quality, reducing the economic pressure towards injecting.
Only very few Albanians inject, they reportedly mainly smoke the
heroin in cigarettes or chase the drug (see Intermezzo: Ali &
Muhammed). Ethnic Macedonians may be more inclined to inject.
|Intermezzo: Ali and Mohammed
"He used to own a Mercedes, a BMW and an Audi," says Ali, pointing at Mohammed,
"but he lost it all, smoked them up, one by one." With a mixture of embarrassment and
laughter, Mohammed nods acknowledging. Risto is driving up Vodno mountain. Macedonia's president
and several ministers are living here, apparently. Risto just picked me up at the "Grand Hotel"
and introduced me to his two Albanian friends. Ali, 20 years, and Mohammed, 21 years, have been using
heroin for about five years now. They started using heroin and cocaine in Germany, where they were
working for a relative, selling the two drugs to German "Fixer". They worked in several
German cities, staying with relatives who were all part of the same Albanian heroin trafficking network.
When the ground became to hot under their feet, they moved back to Macedonia, where they continued
dealing. "Before we went working in Germany, only few people were into using heroin, but when we
returned it seemed as if everybody in Skopje was starting to use. ... That was in 1992." They speak
fondly of that period: "We used to sell a lot of heroin, make a lot of money..." They spent it
just as fast, on clothes, cars and heroin. Lots of heroin. "We used to smoke at least 5 grams a day and
also gave a lot away." Ali explains that they got the heroin on consignment from his father, who lives
just across the Bulgarian border, where he owns a brothel and wholesales heroin. At somepoint they found
themselves spending more money on heroin, than they were making by selling it. Things were getting out
of hand and little of their wealth remained. They are still dealing. Ali uses about 1.5 grams per day,
Mohammed is enrolled in a methadone program. Risto parks the car at a "scenic overlook" as
far from the road as possible. "If the police shows up, then I'm just showing you the view of
Skopje." The view is, indeed, very beautiful as the city is slowly sinking into t
he twilight. The Vardar is as a silver twine running through the landscape. As soon as Risto turned the
engine off, Ali takes a little paper package from his pocket. He opens it and shows me the contents --about
half a gram of brown south-west Asian heroin. With a piece of paper, he scoops a considerable amount of
the powder on the back of his cigarette box and shapes it into one line. Through a rolled up bill he snorts it
into one of his nostrils. In the meantime, Mohammed took out a cigarette and is heating the tobacco, gently
moving the flame up and down the cigarette. &
quot;The tobacco comes out easier, when you dry it a little," he explains in German. He pulls some
of the tobacco out of the cigarette and massages what is left, so that is evenly divided. He gets the heroin
package from Ali and, by scooping and tapping, fills the cigarette with heroin. Then he twists the tip close
and, after some additional massaging and tapping, he lights the cigarette and starts smoking. After Ali
snorted the line, he takes a piece of aluminum foil, which was sitting behind the cellophane of the cigarette
box, and unfolds it. Carefully, he tears of a strip of about 2 inches wide (+/- 5 cm.) and, after rubbing out
all the crinkles with his thumb, he rolls it around a cigarette into a tube. Subsequently he tears of another
oblong piece, rubs out the wrinkles and heats it "... to burn of the coating, you don't want to inhale
that stuff." He performs all these tasks with great care and concentration, signifying their (ritual)
merit. He scoops a littl
e heap of heroin onto the foil, puts the pipe between his lips and starts chasing. Heated from beneath, the
powder turns into a drop and starts to run slowly along the foil, closely followed (chased) by the pipe,
through which the vapors disappear into Ali's lungs. They are uncertain which mode is practiced most,
chasing or smoking in cigarettes. "We do it both. I guess it depends on where you are or who you are
with. Sometimes I snort it," explains Ali. When I ask him whether he has ever injected, Ali almost
gets upset. He vehemently shakes his head and very resolutely says he never did and never will inject:
"That's very bad, it's dirty. You will never see an Albanian injecting." He rapidly translates my
question to Mohammed, who underscores his partner's assertion: "Nein, nein, nicht gut. Man soll das
Recent research suggests that whether heroin users inject or not
is determined by a combination of economic and cultural factors
(Grund & Blanken 1993). The economic factor embodies variables
such as the availability, price and quality of the drug. If heroin
is very expensive and, in particular, of low purity, users are
driven towards injecting. When the drug is relatively cheap and
of reasonable quality, users feel no pressure to initiate injecting.
Over a longer period, stabile resources of constant and adequate
potency allow, for example, for the formation of a chasing culture
--which happened during the 1970s and 1980s in the Netherlands.
Such a culture is built around the development of knowledge (folklore),
(ritualized) skills, rationalizations, rules and sanctions (taboos)
that all support the maintenance of the "chasing ritual"
(Grund & Blanken 1993; Grund 1993; Zinberg 1984).
Being initiated into heroin use in such a situation generally
equals initiation into chasing, while the likelihood of initiation
into injecting is rather small. When economic pressure is low
or absent, transitions towards injecting later on are less likely.
First of all, people tend to stick with the administration mode
of initiation (Grund et al. 1992a). Likewise, there are simply
less IDU role models around and injecting knowledge and skills
are less available. Additionally, becoming known as an injector
among chasing friends may lead to stigmatization and ostracization.
A totally opposite situation developed in the United States where
a highly marginalized injecting subculture evolved around the
use of heroin of extremely poor quality (Des Jarlais et al. 1991;
O'Donnell & Jones 1968).
Within the Macedonian context we can observe evidence of both
developments and they seem to be distributed unevenly along ethnic
lines. While the current heroin availability (in terms of price
and purity) in general is favorable to the development of a heroin
smoking culture (both chasing and smoking in cigarettes), among
Albanian users the phenomenon seems stronger and further developed.
Because of their involvement in heroin trafficking, they will
experience very few availability problems. The claim of some respondents
that "they are sitting on kilo's," and their smoking
the drug in cigarettes (which is a very wasteful way of using
the drug) both attest to this assumption. Likewise, smoking heroin
cigarettes seems to constitute a fairly integrated practice, crossing
generational boundaries. Finally, injecting is perceived as an
appalling activity, a taboo. Ethnic Macedonian users, in contrast,
are more likely to be just customers, having to raise money with
other, more harmful and stigmatizing, and less consistent and
profitable activities. What's more, among ethnic Macedonians,
heroin use seems much more an activity of adolescent youth, strongly
disapproved of by the older generation. In that context, injecting
may serve as the ultimate symbolic protest, expressing the total
rejection of parental values and control.
(Return to Table of Contents)
The prevalence of HIV in Macedonia is currently probably still
very low. Of 22 HIV cases 3 consisted of IDUs, who were presumably
infected abroad. Both in Skopje and Ohrid all drug users admitted
to treatment are tested for HIV antibodies and all persons tested
have been negative. However, nothing is known about sero-prevalence
among out-of-treatment populations or about nature and prevalence
of risk behaviors of Macedonian IDUs.
An important objective of the visit was to gather information
about the context of drug injecting and its potential HIV risks.
Based on discussions with IDUs --both in and out of treatment--
the following picture emerges: Drug users' knowledge about HIV/AIDS
and ways to prevent transmission is very limited. While many users
have heard of AIDS, it is an empty concept for them and they do
not pay much attention to it. The users in the ambulatory methadone
program in Skopje were aware of the (zero) HIV antibody prevalence
in the clinic's sample, but their interpretation of this statistic
seemed to be that they were not at risk, and therefore did not
need to worry about it: "There is no AIDS in Macedonia, that
is not a problem for us here."
Indeed, the fact that the virus has not yet been substantially
introduced into the networks of IDUs is probably the only reason
for the low prevalence. While there are very few barriers to obtaining
sterile syringes --IDU respondents acknowledge their unrestricted
availability in the pharmacies-- IDUs may well be sharing needles
and syringes on a regular basis. As one respondent explained:
"Sometimes you have just enough money to buy the heroin,
but nothing left for a syringe, and some junkies don't want to
spend the money for a new syringe, so they never even bother."
The limitation of daytime opening hours in pharmacies was mentioned
as a reason for sharing needles during the night. Another frequent
reason for sharing is apparently when an IDU would unexpectedly
meet a friend: "I would run into another guy and then we
would use together. If one of us would not have a syringe, we
would use each other's syringe without much thought."
A related matter of great concern is that the police is apparently
testing confiscated needles for drug residue to make cases against
drug users or to secure their cooperation in cases against other
defendants. Many studies have shown that this discourages IDUs
from carrying their own drug injecting equipment, inducing episodes
of 'needle sharing' and (potential) transmission of HIV and other
bloodborne pathogens. This matter was brought to our attention
by some fieldwork respondents and, upon questioning, acknowledged
by Mr. Stojanovski of the Narcotics Department of the Ministry
In particular American research has documented that IDUs apply
several strategies to prevent police detection (Zule 1992). While
lowering the risks of police detection and arrest, these strategies
may increase the risks for HIV infection (Connors 1992). One such
strategy is the use of shooting galleries, places where IDUs go
primarily to inject drugs. Use of shooting galleries has been
positively associated with the chance of being infected with HIV
(Schoenbaum et al. 1989). During the fieldwork I was brought to
a house where reportedly many people go to inject and which fits
the definition of a shooting gallery (see Intermezzo: A Shooting
Gallery in Skopje).
|Intermezzo: A Shooting Gallery in Skopje
This evening Abdul takes me to a house in the old Albanian part of town, across the stone pedestrian
bridge over the Vardar. We walk through a maze of little streets and enter a fenced backyard through a
gate. When Abdul knocks on the door, a voice asks who there is. After Abdul identifies himself and me,
the door is opened by Ahmed, a +/- 28 years old Albanian man. A 2ml. syringe is dangling in his right fist,
half filled with a mixture of drug solution and blood. I shake his left hand, which is covered with abscesses
and sores. We enter a room, which is sparsely furnished, a double bed, a table and a few chairs, a TV and a
few paintings on the walls. After we came in, Ahmed withdrew in the adjacent room and finished his shot.
Another, +/- 40 years old Albanian man is watching television and after a few minutes he starts to nod a
little. Perhaps he snorted some heroin just before we entered. Before we entered, Abdul told me that this
house is frequented by many IDUs. While not as many as in Ghazi Baba, ther
e are a considerable number of dealers in this neighborhood. People who buy heroin and cannot or do not
want to wait to get back home come here to inject their drugs. Others do not have a place where they can
quietly get high, e.g. because they live with their parents or spouse, who are ignorant of their use. Again
others run out during lunch break from work, buy drugs and get high quickly at this place. In return for this
gets a "taste" (a small portion) of their heroin. Other users come here and ask Ahmed to buy
heroin for them. They wait in the house while Ahmed goes out to buy and use when he returns. They also
pay Ahmed with a taste. The place has many characteristics of an informal shooting gallery. It was unclear
whether Ahmed also provides injecting equipment to visitors, but given the reasons why some people visit
the place, this may well be the case. This and similar places may become important vectors in the spread of
HIV. It could, however, also serve as an important locale of education and prevention, as is the case in
several cities in the Netherlands, where outreach workers provide such locales with sterile syringes and
HIV information (Grund et al. 1992b).
While the dangers of sharing needles and syringes are well recognized,
another class of drug injecting related HIV risk behavior has
gotten much less attention. In Macedonia this behavior may also
play a significant role. Much of the pleasure and attraction of
using psychoactive substances --whether these are legal or illegal--
is in sharing the resulting experience. For that reason, psychoactive
substances are often used and shared in a social setting. Think,
for example of offering coffee to guests at the beginning of a
social visit, having a cigarette with a classmate during the morning
break, sharing drinks during the happy hour in the favorite haunt,
passing a marihuana joint at a rock concert, or taking heroin
with one or more friends in an elevator stopped between two flights
--the behavior and symbolic meaning are the same, the drugs are
When IDUs share drugs, they often share the liquefied drug and
use syringes to measure out doses. This behavior is termed Syringe-Mediated
Drug Sharing (SMDS). SMDS has been observed around the world and
includes various techniques, dependent on the type of syringe
(e.g. one-part vs. two-part syringes) (Grund et al 1991; Jose
et al. 1993; Grund et al. 1995). The basic procedure goes as follows:
a certain amount of heroin is prepared as usually (cooked in a
spoon or bottle cap) and drawn into one (donor) syringe. From
a second (receptive) syringe the needle is removed and the plunger
is drawn back. The needle of the donor syringe is then inserted
through the hub at the front of the receptor syringe, and a part
of the solution squirted in. This procedure, termed "Frontloading,"
and other drug sharing techniques puts IDUs at risk for infection
with HIV and other bloodborne pathogens.
Frontloading may well be widely practiced among Macedonian IDUs.
All the fieldwork respondents with injecting experience were aware
of the technique and within their networks it is a very frequent
occurrence. During the discussion with methadone patients at the
Center for the Prevention and Treatment of Drug Abuse in Skopje,
a wave of recognition went through the room when a photograph
of frontloading was shown. This was followed by a lively discussion
among members of the group.
Finally, it is not clear what role (female) heroin users play
in prostitution. There does not seem to be an open street prostitution
area (a stroll) in Skopje or Ohrid. Evidence of the involvement
of drug users in prostitution has not been found.
While it would be premature to draw definitive conclusions about
this issue, the level of drug use related HIV risk behaviors seems
to be unacceptably high. This preliminary assessment is corroborated
by a study into the prevalence of hepatitis C at the Center for
the Prevention and Treatment of Drug Abuse in Skopje. While the
sample consisted of only twenty subjects, a 100% prevalence was
(Return to Table of Contents)
The only profession seriously involved in treating drug problems
is psychiatry. In Skopje drug treatment is provided by the hospital
for Nervous and Mental Diseases "Bardovci." In 1990
Bardovci created drug detoxification facilities in the hospital
and a drug treatment project, "the Center for the Prevention
and Treatment of Drug Abuse," at another location in Skopje.
At this moment +/- 80 people receive treatment in this out-patient
facility. Another 14 patients are treated on the forensic ward
of Bardovci. In Ohrid, the Department of Neuropsychiatry of the
Medical Center Ohrid is providing drug treatment. Two years ago
the number of people applying for help increased significantly
and since then +/- 40 people have been treated.
Treatment in the psychiatric hospitals consists of detoxification,
which may be accompanied by medication and/or vitamin therapy.
Drug users share accommodations with patients with a wide variety
of other psychiatric complaints. Treatment plans, when present,
seem often improvised and not based on established criteria.
The Center for the Prevention and Treatment of Drug Abuse offers
somewhat more comprehensive treatment, ranging from 'cold turkey'
detoxification to long term methadone maintenance. Currently there
are two patient groups: An older group of "hard core addicts,"
who have a long history of opiate use. These patients receive
weekly prescriptions of methadone on a maintenance basis. The
other group consists of younger users with shorter drug use histories.
These come daily or several times per week, often with their parents.
Methadone is prescribed on a reduction basis in combination with
psychotherapy and family counseling.
Methadone is mainly dispensed in liquid (oral) form. The use of
methadone in the treatment of heroin dependent persons used to
be an anathema, but with the advent of the AIDS epidemic this
situation changed. Prof. Jovev, the medical director of Bardovci,
explained that many addicts traveled frequently and concerns over
the introduction of HIV into the Macedonian population via injection
drug users (IDUs) infected abroad has led to a pragmatic adaptation
of this policy.
When alcohol and drug addicts are sentenced to serve prison time,
their sentence may get extended to include the, so called, "Protective
Measure," which is a form of compulsory treatment. Under
this provision some treatment is available in Skopje's prison,
which may include methadone. However, Dr. Levenski, the prison
doctor, is not very positive about the results.
Sentenced drug addicts may also end up in a closed ward of Bardovci
hospital (currently +/- 10). However, security is insufficient
and apparently many addicts escape. Prison authorities, Bardovci
and the ministry of justice are currently discussing the establishment
of a treatment prison for addicts who have received prison sentences.
Treatment of heroin addiction and other drug problems in Macedonia
is still in its infancy. The visits to the treatment facilities
and the discussions with staff, patients and fieldwork respondents
with treatment experience indicated some serious problems.
- There is currently no comprehensive system of care, treatment
and social rehabilitation. What is presently available are detoxification
and some methadone maintenance slots. There are no follow-up social
reintegration programs, nor are there care and support services
available for users who are unable or unwilling to stop using
drugs. HIV prevention programs for (injecting) drug users are
- Treatment philosophies are unclear or under-developed and
tend to put too much emphasis on psychopathology. Social and health
perspectives do not play a substantial role. This is reflected
in the staffing of current programs: psychiatrist outnumber social
workers and health care workers. This is in great contrast with
western Europe and the US, where an average drug treatment program
has maximally one half-time psychiatrist on staff. A related problem
is that the level of knowledge and skills of staff regarding drug
use and addiction is rather limited, while up-to-date information
on the topic is unavailable. There is no access to the professional
literature. Bardovci, which is a teaching hospital, has not received
a foreign publication in 6-7 years. In such a situation one has
to reinvent the wheel, time after time, copying the mistakes made
elsewhere, without the possibility of learning from these examples.
- While the level of heroin use among Albanians is reportedly
very high, few partake in treatment. There may be several reasons
for this: Current treatment services may not be equipped to work
with Albanians (e.g. absence of Albanian staff). Albanian users
may distrust drug treatment services and suspect ties with law
enforcement. An important reason may well be that, because they
have a steady supply of heroin, they have less of a need for treatment.
- The five fieldwork respondents with a treatment history were
rather negative about their experiences. In-patient treatment
in Bardovci, they feel, consists of little more than a bed. Some
did not receive medication at all. The temptation to use drugs
was high in the hospital, as drugs were easy to get. "It
was easier than outside, the dealer would come to my window."
Three ex-users thought that current methadone treatment only sustained
their addiction, as there was no help with their other problems.
One respondent, who was on methadone at the time of the interview,
had experienced a methadone shortage: "Three days without
methadone, then you are forced to use heroin."
- The unstable methadone availability is a result of the conflicts
in the region and the economic blockades. While Macedonia has
a legal opiate industry (Alkaloid in Skopje), it does not manufacture
methadone. The drug is imported.
- The Center for the Prevention and Treatment of Drug Abuse
is currently located in a poorly maintained building on the outskirts
of Skopje. The latter, without doubt, creates a large threshold
to treatment for people without access to a car.
- A problem more generally experienced are the limited financial
resources available for treatment services. According to the staff,
both in Skopje and Ohrid, many activities and improvements are
simply impossible because of financial limitations.
- The primary health care system is not structurally involved
in the care and treatment of problem drug users. This may partly
be due to the practice that methadone can only prescribed to addicts
by the psychiatric hospitals. General practitioners (GPs) can
prescribe opiates, but not in the context of addiction treatment.
This rule is enforced by the Macedonian Medical Association (of
which Prof. Jovev is the president), which has the authority to
withdraw medical licenses.
(Return to Table of Contents)
Very few drug prevention activities have been developed. OSI-M
funded a drug prevention poster campaign some years ago and in
the neighborhood of the Grand Hotel we spotted some drug posters
in a public display. Drugs are a regular and heavily debated topic
in the media, but, according to our sources, these discussions
are rather emotional and rarely based on factual information.
The local alternative radio station "Channel 103" has
profiled itself as an advocate of drug policy reform. The station
has broadcasted public service announcements both advocating the
decriminalization of cannabis and educating their audience on
the dangers of heroin. The editor of the station explained that
they have a close tie with their, largely adolescent, audience
and see the problems brought about by heroin use at close range.
The station is willing to cooperate in developing future drug
(Return to Table of Contents)
HIV prevention is currently not part of the treatment plan in
the treatment centers in Skopje and Ohrid. In terms of knowledge
and counseling skills, treatment staff does not seem equipped
to provide efficient HIV/AIDS education or counseling.
Although the former Yugoslav Federal Law, Article 246 (concerned
with issues of "enabling the use of drugs") criminalizes
the sale of syringes to drug users, needles and syringes can be
purchased freely in public and private pharmacies. This was acknowledged
by several respondents and during the visit three pharmacies were
visited, where syringes could be purchased without a problem.
Dr. Sotirovski, the president of the National AIDS Committee,
asserted that IDUs "can get free syringes in the hospitals
and health clinics." However, other discussion partners took
this statement with a grain of salt. Dr. Sotirovski, also said
that, because of the "high promiscuity among addicts,"
the government had been distributing condoms free of charge among
addicts. However, there was no information available on e.g. the
number of distributed condoms.
HIV prevention campaigns have been directed at the general population
and have emphasized sexual transmission. As far as we could see,
no focused education campaigns have been directed at (injecting)
drug users --or at the gay population, for that matter. These
campaigns have been organized by a non governmental organization
(NGO), the Macedonian Anti AIDS Association.
Several people emphasized that most Macedonian doctors are not
ready to work on AIDS and drugs issues. There is apparently much
resistance to acknowledging the necessity of AIDS awareness and
prevention campaigns. The National Institute of Public Health
is said to be very conservative and not capable of organizing
prevention campaigns. It was suggested to organize prevention
efforts within an NGO framework.
(Return to Table of Contents)
Over the past few years, the police has become increasingly involved
in drug enforcement. The number of discovered offenses (art. 245)
has increased more than 4.5 times between 1990 and 1994, and the
number of persons prosecuted for drug-law offenses, rose to 153
in 1994, some three times more than in 1990. In the period of
1991 - 1994 both the quantities of drugs seized and number of
seizures have increased significantly. The early 1990s witnessed
a considerable rise in the amount of confiscated heroin. While
cocaine was reportedly the new drug on the block, there was only
one particularly large seizure of cocaine in 1990. The police
also reported increased seizures of marihuana, mostly from domestic
sources. (see table 1.) During the last two years more drug seizures
were made at local level.
We have little information on enforcement priorities (we were
promised several statistics and documents, but never received
them), but some of our discussion partners and several fieldwork
respondents commented on the role of the police, while others
spoke of their personal experiences with the police.
Several people said that the police chase after heroin users and
small dealers, while leaving the big traffickers in peace. The
users and ex-users complained about being beaten up by the police
in efforts to get the names of dealers. Others felt that the police
put too much pressure on marihuana users and petty transactions
in the drug, instead of focusing on heroin. They relate the increase
of heroin use among teenagers to this matter: "If the police
would lock off Ghazi Baba and search the houses, they would find
hundreds of kilo's of heroin, but they bother small-time grass
dealers instead." Two respondents, independently, brought
up that the police differentiates between heroin sales to Macedonians
and Albanians: "I don't know whether it is true or just a
rumor, but I heard that the police is telling dealers that as
long as they sell to their own people (Albanians), they will leave
them alone, but if they sell to Macedonians they would get a bullet."
Another worry, expressed by several people, was that an arrest
for the mere possession of one marihuana joint leads to the opening
of a police record, which might give them problems later in life,
e.g. in applying for a job.
An important observation is that the level of violence in Skopje's
drug scene seems to be very low. None of our discussion partners
or the fieldwork respondents mentioned violence to be an issue.
(Return to Table of Contents)
There is presently no comprehensive drug policy in place in Macedonia.
The republic is a signatory of the 1961 International Convention
on Narcotic Drugs as amended by the 1972 Protocol and of the 1971
Convention on Psychotropic Drugs. The drug laws currently on the
book are those of the former federal Yugoslav republic. Drug consumption
itself is not penalized, but drug possession, drug production
and trafficking are penalized with punishment ranging from fines
to imprisonment (Article 245 of the PA SFRY). "Enabling the
use of drugs" is also penalized (Article 246 of the PA SFRY).
The latter can include offering a place to somebody to use drugs
and providing sterile syringes, although the latter is not enforced.
There does not seem to be much coordination between public health
policy and law enforcement policy.
Given the political situation in Macedonia it is unrealistic to
expect significant short term changes. However, in the beginning
of 1995 a commission was set up to prepare a revision of Macedonia's
drug laws. This commission is considering whether to criminalize
use of drugs (which is currently not an offense), whether and
how to improve the "protective measure" and the situation
of drug addicts in prison; can the prison system be used to provide
adequate drug treatment. On the other hand, possibilities of decriminalization
or legalization of marihuana are also discussed in this commission.
(Return to Table of Contents)
In the first half of the 1990s a large number of, primarily young,
people in Macedonia have gotten involved with heroin. Reliable
estimates of the number of users are absent, because scientific
studies into the prevalence and nature of use have not been undertaken.
Current estimates of the total number of heroin users in the country
vary between 2000 and 6210. At the end of 1994, the State Register
of drug users included +/- 850 individuals. These people have
either applied for treatment of problematic drug use (which in
9 out of 10 cases concerns heroin) or have gotten into trouble
with the law (who reportedly are primarily heroin addicts, but
may include marihuana users). Before 1990 some 20 to 30 new names
were registered each year. In 1991 this number was 50, while 390
new entries were added to the register in 1994.
These known cases can be perceived as "the tip of the iceberg."
The actual number of users, the "dark number," can only
be estimated. In order to obtain a reasonable estimate of the
actual number of users, the World Health Organization (WHO) recommends
multiplying the number of known cases with a factor of 6 to 10.
Applying this formula to the State Register would result in an
estimated number of heroin users between 5100 and 8500. Considering
that not all registered individuals are heroin users and that
some may have stopped using or died over the years, a
fairly conservative estimate of the total number of heroin users
would be between 5000 and 6000.
We can conceptualize the use of heroin in Macedonia in terms of
an epidemic. Drug epidemics have "a beginning, a middle and
end" and go through some specific developmental cycles (Hamid
1992). At this moment in time, the heroin epidemic in Macedonia
seems to have entered a period of widespread diffusion and, unless
the availability of heroin can be reduced to (near) zero, it is
expected that the number of heroin users will grow considerably
in the coming years. Given the Macedonian socio-political context
it is unrealistic to expect that (law enforcement) efforts to
decrease heroin availability will have significant results. Following
the epidemic model, we can expect heroin use in Macedonia to reach
its peak in about 5 to 7 years, at a number of users three to
four times as high as the current number. Thus, around
the year 2000 there may be 15,000 to 20,000 heroin users in Macedonia.
We expect that the use of other drugs will also increase. In addition
to marihuana, psychedelics, such as LSD and MDMA (Ecstasy), will
become more available and popular in the coming years among recreational
drug users and in certain segments of nightlife. Cocaine use may
also grow, both among recreational users --who will primarily
be snorting the drug-- and among the current heroin users --who
can be expected to use this drug as they use heroin, i.e. by smoking
and injecting. In particular the latter is a matter of concern
as this will lead to a multiplication of current drug problems.
The over-the-counter availability of several strong psychoactive
drugs will also be responsible for a further growth of drug use.
Use and abuse of these pharmacy drugs is and will not be limited
to "typical" drug users. One of the respondents explained
that both of his parents were using 50mg. of Diazepam daily. Increased
regulation of these pharmacy drugs is advised.
Macedonia's socio-economical and political situation is conducive
to a further increase of drug use. Limited economic perspectives
and the loss of traditional values have resulted in a mindset
among Macedonian youth that is favorable to drug use. This will
result in a high level of experimentation and, in combination
with the absence of balanced and honest drug information, a considerable
number of problematic users. Interventions aimed at prevention
of use will suffer to a large extent from credibility problems,
as many Macedonian youth simply do not trust official (governmental)
sources of information.
Thus, a significant increase in drug use prevalence is
anticipated and this increase will occur fairly independent of
(Return to Table of Contents)
All around the world, the advent of the AIDS epidemic among IDUs
has changed the shape of the drug problem entirely. Whereas addiction
is not necessarily a terminal condition, AIDS is. In many countries
HIV has afflicted large segments of the (injecting) drug using
population and this has resulted in major changes in the provision
of services to this population.
The current situation regarding HIV and drug use in Macedonia
can be summarized as follows: HIV antibody prevalence among treatment
populations is (close to) zero. A minority of heroin users are
injecting. Only very few Albanians seem to inject, whereas ethnic
Macedonians are more inclined to do so. In countries, such as
the Netherlands and Great Britain, IDUs and Chasers are generally
part of different networks. In Macedonia this may not be the case.
A considerable number of users seem to alternate between injecting
and smoking and snorting, while IDUs and smokers seem to mix to
a larger extent. The level of HIV risk behaviors (needle sharing,
frontloading, etc.) among IDUs seems to be unacceptably high.
(The 100% hepatitis C seroprevalence in the, albeit small, treatment
sample is a poor omen.) Knowledge about HIV and safer use is very
low or absent. HIV prevention activities specifically aimed at
IDUs have not been developed and HIV is not really addressed in
The absence of HIV in the Macedonian drug injecting population
can only be contributed to the fact that the virus has not yet
been introduced into the networks of IDUs. This presents a paradoxical
situation: All the ingredients are present for the development
of a human tragedy, which will gravely and greatly overshadow
the personal and familial misery and community expense of drug
addiction. On the other hand, because the virus has not made its
entrance among Macedonia's IDUs, it may be possible to prevent
a large scale HIV epidemic in the country's drug using population.
The potential catastrophe is exemplified by the rapid spread of
HIV infection in southeast Asia. In Bangkok, HIV prevalence among
drug injectors was below 1% until 1987. In September 1988 it reached
32-43%. In Northern Thailand prevalence among IDUs increased from
1% in 1988 to 61% in 1989 (Stimson 1994). The alternative scenario
is presented by Australia, where, as a result of the timely and
aggressive implementation of a harm reduction based HIV prevention
strategy, the prevalence of HIV among IDUs remains under 5 per
cent (Wodak & Crofts 1994).
Thus, in respect to HIV/AIDS, Macedonia is currently in
the privileged, but paradoxical position of having a very low
HIV prevalence among its drug using population, which is engaging
in high levels of HIV risk behaviors. It may well be possible
to prevent an epidemic of HIV/AIDS among IDUs in Macedonia, but
this will require a major educational effort, which must be started
(Return to Table of Contents)
At present there is almost no treatment infrastructure in Macedonia
to deal with the problem of heroin abuse, while a rise in the
demand for drug treatment and care services is to be expected.
With regards to drug treatment the following problems can be distinguished:
- Provision of addiction treatment is not systematically organized
and limited to only two psychiatric institutions.
- Treatment models are underdeveloped and dependent on the individual
concepts of psychiatrists.
- Drug addicted patients are often mixed with alcoholics and
other psychiatric patients --an undesirable situation for all
- Public health services and primary health care providers,
such as general practitioners (GPs) have no considerable role
in prevention and treatment.
- There are not enough trained professionals in the field.
- In the present situation methadone can only be prescribed
by psychiatric hospitals. When prescribed, it is generally on
a reduction basis, maintenance is an exception.
- The legal availability of methadone to treatment providers
is unstable, which has resulted in patients not receiving their
medication. As the drug is imported, this problem results from
the economic blockade.
- The geographical location of the Center for the Prevention
and Treatment of Drug Abuse on the outskirts of Skopje constitutes
an important barrier to treatment.
- Follow-up services after detoxification or social reintegration
programs for people who terminated heroin use or who are maintained
on methadone are absent.
- Harm reduction and HIV prevention services for people who
are unable or unwilling to give up drugs, such as medical care,
overdose and abscess prevention, syringe exchange, or legal counseling,
are equally absent.
In order to provide drug treatment and care to the growing number
of heroin users this situation will need serious improvements.
However, given the precarious economic situation of the country,
the development of a separate and independent system of specialized
treatment and care does not seem likely. It is also not desirable,
as it would contribute to stigmatization and alienation. Likewise,
we cannot expect only one profession, the psychiatrists, to effectively
deal with the rising demand for services.
It is therefore of crucial importance to include the primary health
care system in the care and treatment of drug abusers. General
practitioners, social workers and related professionals will need
to be involved and trained in the provision of services to drug
users. Only when certain services cannot be organized within general
(health care) structures, separate provisions should be created.
Many studies have shown that methadone substitution and in particular
methadone maintenance is the most effective treatment for heroin
addiction (Drucker 1995). It is for that reason advisable to establish
methadone maintenance as the basis of the treatment system. Whereas
maintenance will provide its foundation, flexibility is the main
characteristic of such a prescription policy, tailoring treatment
to the needs and capabilities of individual clients. A comprehensive
treatment system provides a range of options, from maintenance
to detoxification. The latter could be both ambulatory and in-patient;
with or without substitution drugs.
The current restrictions on the prescription of methadone and
other heroin substitutes might be relaxed, so that GPs are able
to prescribe these drugs in the course of addiction treatment.
To improve the legal availability of methadone, the local factory
"Alkaloid" could perhaps produce methadone. Other pharmacological
interventions could also be considered, e.g. Buprenorphine or
Dihydrocodeine substitution, which is used in Germany, or Naltrexone
in relapse prevention.
Methadone treatment works best when part of a comprehensive approach.
Thus, medical care, help with social problems, psychotherapy and
legal counseling, offered on a voluntary basis, would certainly
improve the effectivity of treatment.
Relapse prevention and social reintegration programs further increase
success rates of treatment. Such services might emphasize job
training and forge collaborations with local businesses in order
to provide jobs to former and stabilized drug users.
The agency best equipped to organize the described treatment program
seems to be the Center for the Prevention and Treatment of Drug
Abuse in Skopje. This agency should be relocated to a more central
location in town. From there, it can initiate cooperations with
primary health care providers, such as community health centers
and GPs. The Center might also develop a cooperative relationship
with the drug treatment providers of the Medical Center in Ohrid
in order to share knowledge and organize joint training sessions.
There are currently negotiations going about the establishment
of a treatment prison. Experiences elsewhere indicate that results
of those facilities are far from impressive, while they are very
expensive. Therefore, as long as voluntary treatment has not been
properly organized, it makes little sense to put scarce resources
into compulsory treatment.
(Return to Table of Contents)
Drug education and prevention of drug abuse have not been developed
yet in Macedonia. Such services ought to be organized in a professional
way. At least two types of education programs can be distinguished:
1. primary prevention and provision of general drug information,
and 2. information aimed at (potential) drug consumers. The first
may include school based drug education curricula and information
for parents, while the second pertains to e.g. specific consumer
information about certain drugs, intended to reduce the harm associated
with the use of these drugs. In both types of programs, information
should be presented in a forthright, factual manner and based
on scientific research. Campaigns utilizing fear based messages
can better be avoided, as these have been notorious failures,
both in preventing drug use, and as credible information sources
for consumers. Several good examples of both types of programs
have been developed in Great Britain, the Netherlands and Australia.
These could be translated and adapted to fit the Macedonian context.
Given the existence of a large number of young adolescents who
are currently experimenting with drugs, we suggest to first develop
the second type of education. Good drug education for adolescent
drug consumers targets this group with relevant health information
through credible and culturally recognizable sources. Although
well acquainted with effects of drugs and the potential harmful
consequences of their use, ex-addicts generally do not have the
necessary credit, in particular for (experimenting) adolescents,
because they do not provide recognizable role models. More crudely
put, adolescent drug experimenters do not recognize themselves
in "fuck-ups." Skopje's independent radio station "Channel
103," because of their popularity among many (westernized)
youth, may well provide a good medium to reach the target group.
The station has expressed an interest in working on drug information
(Return to Table of Contents)
The Macedonian HIV/AIDS situation has been extensively discussed
above. Here we will discuss some measures to counter the outbreak
of an HIV epidemic among IDUs. First of all, drug treatment personnel
must be trained to provide HIV education and safer drug use skills
to clients. Treatment programs should also start making sterile
injecting equipment, bleach kits and condoms available to their
(drug injecting) clients. However, it is at least equally important
to reach (injecting) heroin users, who are presently not in treatment.
This can be established through an outreach effort in which medical
professionals, peer educators and ethnographic researchers cooperate.
Such an effort will provide systematic information about the nature,
extent and social context of risk behaviors, while simultaneously
offering low threshold medical care, diffusing HIV information,
teaching safer drug use (and safer sex) skills and providing sterile
injecting equipment to IDUs.
The Macedonian Anti-AIDS Association (MACA) has expressed a willingness
to organize such an outreach effort. This organization has contacts
with several young, enthusiastic and unemployed doctors who are
interested in working on this project.
(Return to Table of Contents)
In the coming period Macedonia will need to develop a drug policy
to deal with the expanding use of heroin and other drugs. This
will not be an easy task, as, for understandable reasons, drug
problems do not rank high on the political agenda. However, this
is not necessarily a disadvantage, as the drug issue can potentially
become the object of political polarization, for example between
Albanians and Macedonians. (1)
It should be understood that such would be a disastrous development,
aggravating the problems at all levels. The drug problem can best
be dealt with outside of the political spotlight.
A choice must be made between a policy that emphasizes law enforcement
(a "War on Drugs" approach) or a policy that puts the
emphasis on health goals (a "Harm Reduction" approach).
Some of our discussion partners expressed the hope that it would
be possible to eradicate the use of drugs in Macedonia. In many
countries around the world this desire has provided the justification
for drug policies emphasizing War on Drugs strategies. However,
The international experience of the past decades shows that, despite
ever increasing law enforcement efforts, the prevalence of drug
use has not decreased. In contrast, in most countries drug problems
have increased, while the global availability of drugs such as
heroin is larger than ever. The latter has resulted in the diffusion
of drug use into new and previously unaffected areas. The emergence
of heroin in Macedonia provides a perfect example.
Not only are its chances of eliminating drug use very small, a
choice for a War on Drugs policy will have several other negative
consequences. Drug related violence is presently not a big issue.
Because of the large financial interests involved in the drug
trade, a War on Drugs policy will lead to a spiral of ever increasing
violence. Likewise, most heroin users do not inject, which, in
terms of public health, is highly desirable, because IDUs are
at great risk for contracting and spreading HIV. When a War on
Drugs policy would be able to reduce the purity of the drugs on
the black market, many heroin users would be pushed towards injecting.
In recent times, several countries have begun implementing "Harm
Reduction" drug policies, which prioritize the reduction
of drug related problems above the reduction of drug use per se.
Recognizing the link between injecting drug use and the global
AIDS epidemic, WHO has recently become a strong proponent of harm
reduction approaches to drug problems. The Netherlands provides
the best example of this approach. In contrast with many neighboring
countries, the drug problem in this country, while highly visible
and in the open, has been stabilized to manageable proportions
(Leuw & Haen Marshall 1994). Dutch law enforcement does play
an important role in managing the drug problem, but it is subservient
to, and coordinated with, public health policy. In fact, several
authors attribute the success of Dutch drug policy more to intelligent
policing than to treatment variables.
In many countries AIDS and heroin use have become inextricable
"Twin Epidemics." In Macedonia it is still possible
to develop a drug policy that will prevent, or at least minimize
such a disaster. This requires that policy making is based on
pragmatism and scientific analysis, and not on wishful thinking
(Des Jarlais 1995). For these reasons we advise to develop a drug
policy based on Public Health and Harm Reduction principles.
(Return to Table of Contents)
Connors MM: Risk perception, risk taking and risk management among
intravenous drug users: implications for AIDS prevention. Soc
Sci Med 1992; 34(6): 591-601.
Des Jarlais DC: Editorial: Harm Reduction --A Framework for Incorporating
Science into Drug Policy. American Journal of Public Health 1995;
Des Jarlais DC, Courtwright DT, Joseph H: The transition from
opium smoking to heroin injection in the United States. AIDS &
Public Policy Journal 1991; 6(2): 88-90.
Drucker E: Harm reduction: a public health strategy. Current Issues
in Public Health 1995; 1: 64-70.
Grund J-PC, Friedman SR, Stern LS, Jose B, Neaigus A, Curtis R,
Des Jarlais DC: Drug Sharing among Injecting Drug Users: Patterns,
Social Context, and Implications for Transmission of Blood-Borne
Pathogens. Social Science and Medicine 1995 (forthcoming)
Grund J-PC, Blanken P: From 'Chasing the Dragon' to 'Chinezen':
the Diffusion of Heroin Smoking in the Netherlands. Final Report.
Rotterdam: Instituut voor Verslavingsonderzoek (IVO), 1993.
Grund J-PC: Drug Use as a Social Ritual: Functionality, Symbolism
and Determinants of Self-Regulation. Rotterdam: Instituut voor
Verslavingsonderzoek (IVO), 1993.
Grund JPC, Blanken P, Kaplan CD, Verveen J, Hartgers C, Hoek JAR
van, Leenders F: The relationship between Dutch drug policy and
injecting drug use: Current injecting and heroin use onset date.
Abstract book VIII International Conference on AIDS, 1992a [PoD
Grund J-PC, Blanken P, Adriaans NFP, Kaplan CD, Barendregt C &
Meeuwsen M: Reaching the unreached: Targeting hidden IDU populations
with clean needles via known users. Journal of Psychoactive Drugs
1992b; 24(1): 41-47.
Grund J-PC, Kaplan CD, Adriaans NFP, Blanken P: Drug sharing and
HIV transmission risks: The practice of "frontloading"
in the Dutch injecting drug user population. Journal of Psychoactive
Drugs. 1991; 23: 1-10.
Hamid A: The developmental cycle of a drug epidemic: the cocaine
smoking epidemic of 1981-1991. Journal of Psychoactive Drugs 1992;
Jose B, Friedman SR, Neaigus A, Curtis R, Grund J-PC, Goldstein
MF, Des Jarlais DC: Syringe-mediated drug sharing (backloading):
a new risk factor for HIV among injecting drug users. AIDS 1993;
Lambert EY, wiebel WW: Introduction. In: Lambert EY (ed.): The
collection and interpretation of Data from Hidden populations,
NIDA Research Monograph 98. Rockville, MD: NIDA, 1990: 1-3.
Leuw E & Haen Marshall I (eds.): Between Prohibition and Legalization:
The Dutch Experiment in Drug Policy. Amsterdam: Kugler Publications,
O'Donnell JA, Jones JP: Diffusion of the intravenous technique
among narcotic addicts in the United States. Journal of Health
and Social Behavior 1968; 9:120-130.
Schoenbaum EE, Hartel D, Selwyn P, Klein RS, Davenny K, Rogers
M, Feiner C, Friedland G: Risk factors for human immunodeficiency
virus infection in intravenous drug users. New England Journal
of Medicine 1989; 321(13): 874-879.
Stimson GV: Reconstruction of subregional diffusion of HIV infection
among injecting drug users in southeast Asia: implications for
early intervention. AIDS 1994; 8(11): 1630- 1632.
Wodak A & Crofts N: HIV revisited: preventing the spread of
blood-borne viruses among injecting drug users. Australian Journal
of Public Health 1994; 18(3): 239-240.
Zule WA: Risk and Reciprocity: HIV and the injection drug user
Journal of Psychoactive Drugs 1992; 24(3): 243-249.
Zinberg NE: Drug, set, and setting: The basis for controlled intoxicant
use. New Haven: Yale University Press, 1984.
(Return to Table of Contents)
On the day of arrival the team met with Dr. Ratka Kuljan, program
coordinator at OSI-M and Dr. Ivan Tulevski, chairman of the OSI-M
working group on the drug abuse program. This meeting served as
a mutual introduction in which the goals of the mission and the
schedule of the visit were discussed. Dr. Tulevski, chief of the
Center for Treatment and Prevention of Drug Abuse of the psychiatric
hospital Bardovci, has accompanied us at many of the meetings,
often providing important background information. Over the course
of the visit the other members of the working group, Ljupcho Todorovski
and Dancho Chevreski were also met. Mr. Todorovski, a narcotics
officer, has also been present at many of the scheduled meetings.
Hospital for Nervous and Mental Diseases "Bardovci"
in Skopje, Prof. Dr. Jordan Jovev, dir., Prim. Dr. Ivan Duridanov,
dep. dir. and Duanka Crvenova, principle nurse. Also present
is Prim. Dr. Ivan Tulevski, head of the out-patient drug treatment
clinic (see Monday, March 13) and one of our hosts.
Bardovci is a psychiatric hospital, built more than 20 years ago
and very poorly maintained. Premises and furnishing are in a dilapidated
condition. Medical equipment present (e.g. EEG machine, dental
clinic) is about just as old as the buildings and also in substandard
condition. The hospital's library (Bardovci is also a teaching
hospital) has not received a foreign language book or professional
journal in 6-7 years.
Bardovci houses about 750 patients in total, of whom +/- 300 go
home on the weekends. Until recently the hospital had a joint
department for the treatment of addiction to alcohol and drugs,
but these were separated last year because of the increase in
the number of drug users applying for (or being sent to) treatment
at the hospital. For that reason they have created a new team
solely dedicated to drug treatment.
The first cases of drug addiction became visible in 1969: 11 cases,
but these consisted mainly of doctors, nurses and other medical
providers with easy access to opiates and other drugs. Before
1990 they were mostly confronted with use of raw opium and morphine,
which was mainly injected. Until 1990 there were about 20-25 new
cases yearly. Individuals would apply for treatment voluntary,
brought by the police, or sentenced by the court to receive compulsory
treatment (called "a protective measure"). In those
days, Prof. Jovev says, they have treated 600 addicts, of whom
400 stopped using. They were left with about 100 "hard core"
Prof. Jovev explains that drug addiction is a very contemporary
problem, but that alcoholism is a much larger chronic problem
in Macedonia (he estimates the number of alcoholics in Skopje
at +/- 15.000 and for Macedonia at +/- 40.000). He hopes that
the problem of drug addiction can still be extinguished.
Youth Council of Macedonia in Skopje, Darvo Serafimovski,
The Youth Council of Macedonia (YCM) is an umbrella NGO, representing
around 100.000 (Macedonian) youth in 20-30 youth organizations.
The organization has taken the place of the former Communist Youth
Leagues and is well-locked into the government and European youth
organizations. Although in 1993 YCM organized a round table on
the legalization of soft drugs (cannabis), the drug issue is not
a high priority on YCM's agenda. Knowledge about drug use and
related problems is limited, perhaps largely because the organizations
YCM represents are not the environments in which initial experimentation
with illicit drugs is likely to occur. However, the organization
is generally aware of the problem and considering future activities
around information provision and education.
The Narcotics Department of the State Ministry of Interior,
in Skopje, Mr. Trpe Stojanovski, law enforcement officer and statistical
analyst. Later we are joined by the deputy minister of interior
Mr. Stojanovski opens the meeting with a quote of the minister
of interior: "80% of the drugs that are brought into Macedonia
are caught." Mr. Stojanovski emphasizes that this is the
opinion of the minister and says that he does not brag about the
data he is about to present. What follows is a fairly open presentation
of and discussion about law enforcement information on use and
sales of illicit drugs. However, this open atmosphere changes
when the deputy minister enters the meeting. Our original schedule
included meetings with local law enforcement in Tetovo and Ohrid,
but Mr. Stojanovski explains that this was not deemed opportune
at the ministry.
Macedonian Center for International Cooperation (MCIC)
in Skopje, Sasho Klekovski, M.D.
MCIC is a humanitarian relief and development organization funded
by a.o. European ecumenical churches. One of their main projects
is improving the water quality in the villages in the western
part of Macedonia. Many of these are Albanian settlings and, according
to Mr. Klekovski, the drug trade has become a strong undercurrent.
Many of the families are not only involved in trafficking, but
also use heroin. "No single family is without use or smuggling."
Mr. Klekovski emphasizes the social determinants of the expansion
in drug use in Macedonia: the breakdown of traditional societal
structures; loss of values and perspective; the economic decline;
a 30% unemployment rate; the return of migrant workers. Mr. Klekovski
observes a lot of resistance in Macedonian society when it comes
to acknowledging issues around homosexuality, drug use and AIDS.
He wonders whether the national public health system is capable
of adequately responding to these health crises.
Ms. Teuta Arifi, television journalist in Tetovo
Mrs. Arifi, an Albanian journalist has little information on the
drug issue as such, but provides us with a larger socio-historical
perspective on the transition Macedonia is undergoing with an
emphasis on the ethnic and gender ingredients. She, too, emphasizes
that the reasons to use drugs are present: unemployment, depression,
lack of perspective, hopelessness. She feels that the school system
could play an important educational role in building an open multi-ethnic
society, but is currently not doing so: "Children loose a
lot of time in school learning about the number of power plants
in the Czech republic, instead they should get health education,
human rights and tolerance."
Medical Center Ohrid, Department of Neuropsychiatry in
Ohrid, Dr. Nikola Tuntev, director, Gjuladin Gjuladin, deputy
director, Prim. Dr. Pavel Sotiroski, Dr. Snezana Strezoska, Dr.
Tanja Tockova (all three psychiatrists)
Ohrid is the main town at lake Ohrid, the largest natural lake
in the country. It is a beautiful lake which draws many foreign
and (increasingly since the boycott and visa requirements) Macedonian
tourists. Because of its touristic status, Ohrid experiences many
"big city phenomena," such as gambling, prostitution
and drug use.
We meet in the director's office which is decorated with a large
portrait of marshall Tito. The medical center started to experience
a rise in drug problems about two years ago. Currently, there
are about 200 "registered drug addicts" on a population
of 75.000, but our discussion partners still feel that drug use
is incidental and they hope to prevent it from happening/spreading.
The meeting has a somewhat forced character, in particular when
subjects such as HIV prevention and condoms are addressed. For
that reason, Dr. Tulevski (our escort) proposes not to burden
the directors' busy agendas any longer and to continue the meeting
with the psychiatrists only.
It is made clear that knowledge about and experience with drug
problems is still limited, which is reflected in the treatment
approach: drug users are mixed with patients with a wide variety
of psychiatric complaints and addiction treatment is often improvised
and not based on established criteria. Likewise, many basic resources
are absent. Dr. Sotiroski asks for support in establishing a separate
drug treatment facility, computers, research and laboratory facilities.
HIV awareness is limited and prevention activities are not part
Macedonian Anti-AIDS Association (MACA) in Skopje, Sofija
Matovska Kunovska & Goran Vesov, M.D.
Ms. Matovska and Dr. Vesov represent the management of the Macedonian
Anti-AIDS Association, a NGO involved in information-based HIV
prevention (AIDS awareness) campaigns. They are a member of EUROCASA
and have received funding from OSI-M and MCIC. Their activities
include "countless" media presentations, production
and distribution of information brochures in Macedonian and Albanian,
a coordinated poster campaign, badges, etc. Campaigns have been
aimed at the general population, drug users (or gays) have not
been targeted as a group. Likewise, there is very little knowledge
about drug use and (beyond "don't share needles") the
relationship with HIV within MACA. This lack appears to be more
general, as Dr. Vesov thinks that there is no conception in Macedonia
about how to deal with HIV issues or how to include these in (drug)
treatment and prevention. While there are several governmental
commissions erected around AIDS, non are viewed as very active
or effective. MACA is currently thinking about new projects. The
question whether this organization would be able and willing to
provide the organizational framework for an HIV prevention (outreach)
effort aimed at (injecting) drug users comes somewhat as a surprise
but generates a serious interest. Dr. Vesov and Ms. Matovska will
investigate the feasibility of such a venture. (Note: later communications
with Dr. Vesov confirm MACA's interest. Dr. Vesov has identified
several young, enthusiastic, but unemployed doctors who are interested
in working on the project.)
Center for the Prevention and Treatment of Drug Abuse in
Skopje, Prim.Dr. Ivan Tulevski, psychiatrist and head of the department,
Dr. Slavica Gaidazdis Knezevik, Dr. Violeta Kiteva, Dr. Dimitar
Bonevski (all three psychiatrists), Anica Zdravevska, psychologist,
Slavica Sekutkovska, social worker
The center is the outpatient drug treatment clinic of Bardovci
hospital. My visit consists of 3 parts: first I am introduced
to the group of parents involved in the treatment of their heroin
addicted children. Next I talk with the patients and then I meet
with Dr. Tulevski and his staff.
A group of parents of drug addicted children is almost never a
happy gathering and this was no exclusion. One by one these tormented
elders told their stories. colored by fear and worries about the
health of their children, misunderstanding and ignorance about
their drug use, fear of stigmatization, doubts about the treatment,
and the burden of their participation in the program (many of
them drive their children across town to the treatment center
--which is located on the outskirts of Skopje-- to pick up methadone
or undergo group- or psycho-therapy). While staff was in the room,
parents were, although subdued, vocal about these problems. After
a while the meeting got interrupted by several requests from patients
for their methadone. Apparently parents and children had been
waiting for my arrival (and in the case of the patients, their
methadone) some time, and the young men were getting impatient.
When the patients entered the room, parents and staff left and
I was left with my interpreter and a room full of rather hostile
adolescents, mostly men between 18 and 25 years of age. I was
the reason for the delay in their being medicated, but by asking
a series of questions about issues that are meaningful to them
(the whereabouts of scoring, preparing and using dope), I was
able to engage them in some dialogue about drug use and administration
patterns, HIV risk behaviors, HIV awareness and safer use. Their
stories and answers to my questions provided support to several
assumptions and testimonies, generated by the fieldwork, about
the distribution of use, administration, and selling patterns
in different ethnic groups, the level of HIV risk behavior among
injecting heroin users, etc..
The discussion with Dr. Tulevski and his team revealed the difficulties
of providing adequate drug treatment services with severely limited
(financial) resources. It has happened more than once that patients
could not be medicated, because the clinic was not able to secure
the necessary Heptanon (methadone). Likewise, their facility is
in a poor state of maintenance, located in a very remote neighborhood
with dilapidated access roads. This location presents a significant
barrier to services for people for whom a car is not available.
Not only the building is in bad shape, the little furniture available
as well. Some rooms are furthermore empty: the windows cannot
be closed tightly, but there is also no furniture to equip them.
State Penitentiary in Skopje, Mr. Stoiko Antovski, prison
director Dr. Mihail Levenski, medical director and Ms. Milka Ristova,
a former criminal judge, currently working at the ministry of
justice and member of a working group which is preparing a revision
of Macedonia's drug laws.
Of the +/- 200 prisoners in this jail 20-30 are (known) drug addicts,
their primary drug being mostly heroin (within a polydrug use
pattern). These offenders are 18-38 years old, but the younger
ones are in the majority and on the increase. They significantly
disturb the prison regime, in particular when they "get into
a crisis" (withdrawal). Opiate dependent prisoners may be
put on methadone, followed by "treatment." It is, however,
unclear what this treatment consists of. Dr. Levenski experiences
problems with procuring methadone. When methadone is not available,
it is substituted by neuroleptics, but this is not really successful.
A number of sentenced drug addicts are sent to a closed ward in
Bardovci hospital (currently +/- 10), but security is insufficient.
For that reason, Mr. Antovski would like to see a treatment prison
for addicts who have received prison sentences. Negotiations on
this matter are going on between prison authorities, Bardovci
and the ministry of justice.
When she was a judge, ms. Ristova presided over many drug cases.
The courts have experienced a considerable increase in drug cases.
Between 1945 and 1980 there were only 40 drug cases in total.
In the 1980s there were about 5-10 drug cases yearly. From 1990
on the courts have dealt with +/- 100 cases and especially after
1992 drug cases increased strongly. Ms. Ristova explains that
known alcohol/drug addicts, when sentenced for e.g. acquisition
crime, can also be sentenced to a, so called, "protective
measure," which is a form of compulsory treatment. When such
treatment fails, the offender is sent back to prison to finish
the sentence; when successful the sentence is reviewed. In practice
the latter hardly happens: the results of the protective measure
have been zero with drug using offenders. It is felt that this
is largely the result of the absence of resources to provide adequate
Ms. Ristova is also a member of a commission set up in the beginning
of 1995 to prepare a revision of Macedonia's drug laws. This commission
is considering whether to criminalize use of drugs (which is currently
not an offense), whether and how to improve the protective measure
and the situation of drug addicts in prison; can the prison system
be used to provide adequate drug treatment. On the other hand,
possibilities of decriminalization or legalization of marihuana
are also discussed in this commission.
Brian Shott, program officer at International Resources Exchange
(IREX) in Skopje.
Mr. Shott, an American anthropologist has been studying Macedonian
society, in particular the relationships between the different
ethnic groups, as field research for a Ph.D. study. He does not
have specific information on drug use and trafficking, but feels
that this issue has a potential of being politicized in inter-ethnic
conflicts. His organization would be interested in helping to
develop internet-based information dissemination to improve the
development of drug policy and services.
Mirche Tomovski, editor of Puls, a weekly magazine
Mr. Tomovski can provide only limited information on specific
drug matters, but sketches the larger picture of the transitions
Macedonia is going through: It is a complicated time; the transition
process has lead to the devaluation of traditional institutions
and values, while new ones to replace them have not been developed
yet. Organizing democracy and a free economy are not easy tasks
and lead to new, previously unanticipated problems. The people
of Macedonia are divided, economically, religiously and ethnically.
However, at the level of ordinary people these differences are
not so sharp, but politicians politicize and sharpen these differences.
Interestingly, Mr. Tomovski notes, the relationships between Albanians
and Macedonians in drug dealing circles is better than average:
"You do not worry whether the relationships between different
national groups will be okay as long the relationships between
criminals of the different groups is okay."
While Skopje is the (legal) business center of Macedonia and the
main drug scene, according to Mr. Tomovski it is not the center
of the drug business. The bulk of the large transactions are conducted
in Tetovo, Ohrid and the smaller (Albanian) villages. "In
Ohrid the fish is cheap..." Many of these villages maintain
dynamic connections with "a diaspora of migrant workers."
The Public Health Institute of the Republic of Macedonia
in Skopje, Prim. Dr. Sotir Sotirovski, Epidemiologist, President
of the National AIDS Committee, Head Department of Tropical and
quarantine diseases, AIDS
Dr. Sotirovski presents me with the official government version
of Macedonia's response to HIV. He explains that Macedonia has
a great capacity to deal with infectious diseases through the
national public health system and regional health centers. There
is, however, a lack of funds to maximize the use of these human
In 1985 Macedonia initiated an AIDS program, consisting of two
- Implementing HIV prevention in the health system, e.g. abandoning
glass syringes, testing the blood supply, etc.;
- Health education for the general population through regional
A big school campaign is planned. However, only modest funds are
1.Macedonian politicians may
blame the availability and use of heroin on Albanians, who, indeed,
seem to dominate heroin trafficking. However, the Albanian population
is, at minimum, equally afflicted by heroin use. Overall, heroin
use cannot be explained by just one factor -- the availability--,
but is the result of a combination of many, often intertwined,
factors. Nevertheless, the potential for politization is present
and in the current conflict with Greece it is already exploited.
Just like Macedonia, Greece has experienced a considerable increase
in heroin use in the first half of the 1990s. Hardline greek politicians
claim that Macedonia is behind this, trying to corrupt the Greek
youth, so that they would not be able to defend their country
in case of "a Macedonian invasion." (back)