Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694864737732.pdf (Georgia)
Drug Situation in Georgia 2018 Executive Summary Highlights § No consistent institutional mechanisms for primary prevention exist in the country § Use of illicit drugs (other than marijuana), including new psychoactive substances, among youth is alarmingly high § Prevalence of injecting drug use is one of the highest in the world § Heroin, buprenorphine and home-made ephedra preparation are the major injection drugs § There has been a remarkable increase in treatment and harm reduction service provision in recent years § Significant decrease in street drug testing and imprisonment for drug related offences in recent years § Remarkable shift in marijuana policy – move towards legalization of recreational use in a private space § Lack of data on non-injection, non-problem drug use (club drugs, NPS) § No drug monitoring infrastructure exists § No early warning system in place.
This English summary document presents major findings of the full-length report which is available in Georgian at www.altgeorgia.ge.

In the absence of a formal drug monitoring infrastructure and the national drug monitoring centre in Georgia, the original/parent report was developed as a collaborative effort by a group of dedicated professionals working in the field of psychoactive substance use and public health.

The executive summary was compiled by Tamar Mgebrishvili, MA and David Otiashvili MD, PhD.
Suggested citation for the parent report: Beselia A., Gegenava V., Kirtadze I., Mgebrishvili T., Otiashvili D., Razmadze M., Sturua L., Kutelia L., Javakhishvili J.

(2019).

The Drug Situation in Georgia 2018.

Tbilisi, Georgia.

2 Primary preventioin The system/infrastructure for school-based or community-based universal, targeted or selective prevention is non-existent in the country.
Preventive activities are limited to fragmented fear- based anti-drug campaigns in public schools or media (with no quality assurance mechanisms in place) and/or small-scale short-term pilots implemented by non-governmental organizations within the framework of specific donor-funded projects.

According to national school curriculum, use of psychoactive substances is discussed as a part of healthy lifestyle within several school subjects such as biology, civil education and physical education.
Drug use in general population Substance use among youth was assessed within the European School Survey Project on Alcohol and Other Drugs (ESPAD) in 2015 (NCDC 2016).

Eighty five percent of students (86% of boys and 83% of girls) reported use of alcohol at least once in their lifetime, 43% reported using alcohol in the last 30 days.
Eleven percent of students (19% of boys and 3% of girls) said that they had tried cannabis products at least once in their lifetime; 8% (14% boys and 1.5% girls) used cannabis in the last 12 months, and 4% of students (7.2% boys and 0.6% girls) reported using cannabis in the last 30 days.

Eleven percent reported trying tranquilizers and sedatives without doctor’s prescription, 12% reported using inhalants and 7% reported trying new psychoactive substances (NPS) at least once in their life.
Lifetime use of illicit drugs (other than marijuana), sedatives, inhalants and NPS was about twice higher than average EU estimates for lifetime use of these substances – see Figure 1.

Figure 1.
Figure 1.

Use of psychoactive substances by Georgian students (16 years old) 48% 43% 41% 35% 21% 18% 60% 50% 40% 30% 20% 10% 0% Georgia EU 16% 11% 8% 5% 11% 6% 12% 7% 7% 4% Tobbaco L M Alcohol L M Drunk L M Cannabis LT Other drugs LT Sedatives LT Inhalants LT NPS LT Note: LT – lifetime, LM – last month The (only) General Population Survey on Alcohol, Tobbacco and Drug Use was conducted in 2015.
The national-scale household survey covered representative sample of 4,805 respondents aged 18- 64 (Kirtadze, Otiashvili, and Tabatadze 2016).

Some 90% of the study population had tried alcohol, with male-female differences such that males were more likely to have consumed alcohol recently as compared to females.
An estimated one in ten men consumed alcohol 2 to 3 or more times a 3 week; almost a quarter of current alcohol drinking males consumed 7 or more standard drinks on average at every drinking episode.

An estimated 1.6% of the total study population scored at “problem drinking” levels as defined by the AUDIT, which level might require consultation by a specialist or referral for diagnostics and treatment.
For tobacco smoking, there also was a noteworthy difference in estimates across males and females in all geographic regions.

Overall, an estimated 60.5% of males and 8.6% of females were current smokers.

More males than females smoked frequently (more days in last month) and more heavily (more cigarettes per day).

An estimated 15%-16% of respondents have ever tried cannabis, 32% males and 2.9% females among them.

In some regions more than 70% of males had ever tried cannabis products.
Prevalence of current use of cannabis (defined as last month use) was estimated as 1.2%; however, in some regions more than 8% of males were found to be current cannabis users.

The survey found very little use of inhalants, ecstasy, LSD, cocaine, amphetamines (including methamphetamine), home- made stimulants, heroin, opium, and other opioids such as methadone and buprenorphine, as well as new psychoactive substances.
Notably, the Randomized Response Technique (RRT) component implemented along with the standard GPS survey suggested that the standard approach might have produced under-reporting of illegal drug use in Georgia (Kirtadze et al.

2018).
2018).

Injection drug use Population size estimation (PSE) studies to estimate the number of people who inject drugs (PWID) were conducted in Georgia in 2009, 2012, 2014 and 2016 (Sirbiladze and Tavzarashvili 2012, Public Union Bemoni & Curatio International Foundation 2017, Bemoni Public Union 2010).

The expert consensus meeting and agreement on the outcomes of the studies complemented each study.
Results of all four size estimation studies suggest steady increase in a number of PWID in recent years - see Figure 2.

Figure 2.
Figure 2.

Estimated number of people who inject drugs 45,000 49,700 52,500 40,000 60,000 50,000 40,000 30,000 20,000 10,000 0 2009 2012 2014 2016 According to the last PSE study and expert consensus, the estimated number of injecting drug users was 52,500 in 2016 (50,000-56,000), prevalence was 2.24% (2.13-2.39%) for 18-64 year old population and 1.41% (1.34%-1.51%) for the general population.
Based on the UNODC 2017 World 4 Drug Report this estimate represents third highest prevalence of injection drug use in the world (UNODC 2017).

It is also estimated that out of 52,500 PWID about 22,000 are dependent on opioids.

There are number of distinct characteristics that can be attributed to Georgian injection drug scene.

Polydrug use is prevalent – people largely use whatever is available to them (Otiashvili et al.

2016).
2016).

Small-scale home-production of injectable opioids and stimulants is a common trend (Otiashvili, Kirtadze, and Bergen-Cico 2017).

Injection frequency is remarkably lower if compared to other locations – 5-14 injections/month on average (Kirtadze I.

2018).

Types of specific substances injected by Georgian PWID are presented in Figure 3.

These data is a compilation of information from two major sources.
The first was a program database of the Georgian Harm Reduction Network (GHRN) – a non-governmental non-profit organization that runs 14 low threshold programs in 11 cities and is a single major provider of harm reduction services to PWID in Georgia.

Starting from 2007, GHRN has collected data on socio-demographics and injection practices (including drugs injected during last month) among current injection drug users utilizing its services.
Respondents for this annual, brief (16 questions), paper based survey, administered by social workers at each site, were recruited based on a convenient sampling among the clients of needle exchange programs in all 11 cities.

Total sample size varied from 1,200 to 2,500 depending on a year of the survey.

Data were entered into excel database and results of a descriptive analysis were reported by GHRN systematically.

Figure 3.
Trends of using specific injection drugs used by PWIDs (2002-2018) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2002 2004 2006 2008 2012 2014 2015 2016 2017 2018 Heroin Bprenorphine Vint/Jeff Desomorphine Connifer Vint Note: desomorphine – home-produced opioid, result of acetylation of codeine; Vint/Jef – home-produced meth/amphetamine, result of reduction of ephedrine containing medicine; connifer Vint – home produced meth/amphetamine, result of reduction of ephedrine (from epherda plant); due to use of multiple substances the sum of values exceeds 100%.
The second source was a biannual Bio-Behavioral Surveillance Survey (BBSS) that has been implemented since 2002 in major cities.

BBSS has been implemented by the consortium of public 5 and private research agencies and has employed standardized methodology for all waves of the survey.

This anonymous, paper-based, interviewer-administered survey, among other data, has been collecting information on current use (last week use for 2002, 2004, and 2006, and last month use for 2008, 2012, 2014 and 2016).
The survey utilized Respondent Driven Sampling approach and recruited on average 1,600 current injection drug users for each wave in six largest cities of the country.

For the purpose of current report we summarized the results of descriptive analysis of GHRN and BBSS surveys.

The primary outcomes of interest were prevalence and patterns of illicit drug use, measured through indicators of current use of major injection drugs: heroin, buprenorphine, home-made ATS, and home-made opioids (desomorphine).
Use of New Psychoactive Substances (NPS) Substance use related research in the country has largely focused on a problematic use in the context of traditional (for Georgia) injection drugs, such as opium, heroin, buprenorphine and stimulants.

Recent studies, however, report on increasing trend of consumption of NPS among injection drug users.
The last biennial survey of a representative national sample of people who inject drugs (PWID) documented twofold increase of current NPS use (defined as use in last 30 days) between 2015 and 2017 – 7.1% and 14.4%, respectively (Curatio International Foundation & Bemoni Public Union 2017).

In another study (GHRN client survey), the prevalence of current use of NPS in clients of needle and syringe programs in 2017 was 26% among female and 14% among male beneficiaries (Kirtadze I.

2018).
2018).

Importantly, both studies point on a diverse set of terms used to name different NPS, and the challenges associated with this lack of “standardization” of terminology.

The term “bio” has been originally used to name all and any NPS, and possibly originated from the users’ perception of a herbal (natural, bio) nature of ingredients added to NPS mixtures.

However, currently this term (separately, just “bio”) almost exclusively is used to name synthetic cannabinoids.
“Bio” is also often added as a prefix to the name of a substance indicating which conventional drug the specific NPS is mimicking (bio-amphetamine, bio-MDMA, bio-LSD).

There are very limited or no data on the prevalence and patterns of NPS use in other groups of population.

The only relevant study is an online survey of individuals using new psychoactive substances (23% females) with about half of respondents reporting use in a club setting (Subeliani et al.

2019).
2019).

Cannabis-, MDMA-, and LSD-type substances were most often used by this group.

Compared to males, female respondents were more likely to report the use of MDMA and ketamine in the past 12 months.

The majority obtained their new psychoactive substances from friends and used such substances in a group of friends.

Compared to male respondents, female respondents were more likely to look for drug related information among their friends.
Females were also less likely to obtain drugs using mobile applications.

Respondents identified a range of negative (less energy, depression, problems with coordination) and positive (normalization of sleep, increased appetite, better mood) health and social effects and linked them to the consumption of a particular substance.
6 Drug use in a nightlife setting The electronic music scene has been dynamically developing in Tbilisi, turning the city into the regional hub of electronic dance music (EDM) with a number of nightclubs and festivals considered to be among the best in Europe.

There has been a descent amount of fragmented media reports suggesting the presence of illicit drugs in Georgian EDM environment.

However, reliable data on this emerging phenomenon are extremely limited.
One study describes experience of frequent nightclub goers with use of illicit psychoactive drugs in a club setting (Beselia, Kirtadze I., and Otiashvili 2018).

Authors conducted 16 qualitative in-depth interviews with young nightclub visitors in Tbilisi with the history of club drug use.

The majority of respondents had experience with two and more drugs consumed in a club setting with most prevalent substances being MDMA/ecstasy, amphetamine and synthetic cannabinoids.
Most respondents had limited information regarding the drugs they consumed.

Often this information was provided by dealers or friends and was limited to the name of drug (but not a substance) and its expected effects.

Receiving (often unknown) substance from unknown people was prevalent.

The majority of respondents reported combining psychoactive substances with alcohol or mixing substances.
Participants’ accounts indicated lack of knowledge about adverse effects of drugs, as well as overdose signs and response strategies.

Results of this research are important for guiding future efforts to investigate the prevalence and context of club drug use in the country, to assess health risks associated with it, and to propose strategies to mitigate those risks.

The second study was an online survey among frequent club goers (Otiashvili et al.

2019).
2019).

Mean age of participants (45% females) was 24.4 (SD=5.5), more than two-thirds visited clubs/festivals more than 5 times in the past year.

Three-quarters of the sample (and 37% of females) used illicit psychoactive substances in the past 12 months, and 60.4% reported using such substances in the past 30 days.

The main substances used during an individual’s last episode in a club/festival setting were MDMA/ecstasy, cannabis, and ketamine.
Males and frequent EDM event visitors were more likely to use drugs in the past 12 months.

About 1 in 10 past-year PS users reported experiencing a drug overdose.

Treatment demand Treatment for substance use related disorders Treatment for substance use related disorders is provided by both public and private facilities.

There were 10 “narcological” (addiction treatment) clinics providing in- and out-patient abstinence-oriented treatment in the country (8 of them in the capital city Tbilisi).
In 2018 these clinics served 2,472 patients (1,545 in-patients).

There were 18 state-funded sites in all major cities and 2 sites in prisons providing opiate substitution treatment.

These sites served 8,258 patients (41 females) in 2018.

Since 2017 funding for these programs has been fully provided by the state.

Limited number of abstinence oriented in-patient treatment episodes are also covered from the state budget.
In addition to state funded opiate substitution treatment, there were 10 private (commercial) sites offering buprenorphine (Suboxone®) maintenance treatment for a fee to some 7 3,921 patients.

Overall, there has been a stable scale up of substance use related treatment in the country – see Figure 4.

Figure 4.
Figure 4.

Number of patients enrolled in abstinence oriented and OST programs in 2003-2018 14000 12000 10000 8000 6000 4000 2000 0 Detox OST 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Harm reduction In Georgia, implementation of harm reduction programs, including NSP, started in 2003 and since then have expanded in scope and the scale.
In 2018, there were 16 fixed sites (in 13 cities) and 8 mobile harm reduction units operational in the country (Georgian Harm Reduction Network 2019).
In the Georgian context, “harm reduction” refers to low-threshold services that include provision of needles and syringes, condoms, naloxone for overdose prevention, voluntary counseling and testing (VCT) for blood borne infections, case management and social support, referral to specialized medical and non-medical services, and provision of information and education materials.

In 2018 these programs provided HIV/HCV rapid testing to more than 22,000 PWID and their partners.
As of 2018, all harm reduction services are fully funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Services in prisons As of December 2018, there were 8,053 individuals (279 females) in a prison system in Georgia.

Short-term opiate substitution treatment is available in 2 (out of 15) prisons.

This treatment serves detoxification purposes, is limited to 3-month period, and can be provided to individuals who were on OST prior to imprisonment or can be initiated in prison.
In 2018 this treatment was provided to 763 inmates.

Voluntary counseling and testing and treatment for HIV/AIDS, hepatitis C virus and tuberculosis is available to all prisoners.

There are no needle and syringe programs and no long- term opiate substitution treatment implemented in prisons.

In-patient detoxification treatment is available in a special ward in a central prison hospital; however, there are no data on a number of individuals treated (if any).
Drug related infectious diseases 8 HIV prevalence among PWID in Georgia is relatively low and varies between 1% and 7% depending on a location (Curatio International Foundation & Bemoni Public Union 2017).

However, the annual incidence of HIV in Georgia has steadily increased over the last decade by 10-25% (UNAIDS 2016) and has reached 18.1 per 100,000 population in 2016 (ECDC 2017).
About 38.2% of cumulative HIV cases in the country are attributed to injection drug use and 16.2% of new HIV cases in 2018 were linked to injection drug use (Centre for Infectious Disease 2018).

Georgia has implemented ‘treat all’ policy since 2015, and all HIV positive individuals have been offered antiretroviral therapy (ART) regardless of immune status or disease stage.

Nevertheless, the significant gap in the identification of new cases, and late diagnosis represents major challenge.
Only 48% of the estimated number of people living with HIV is aware of their status.

While PWID and men having sex with men (MSM) remain the most vulnerable groups with the highest prevalence of HIV, only 23.3% of PWID are covered by prevention programs (Curatio International Foundation & Bemoni Public Union 2017).

Considering the situation with the late diagnosis and growing prevalence of HIV in the country, the major challenge is to increase testing uptake and linkage to HIV/AIDS care.
Prevalence of hepatitis C virus (HCV) among injection drug users is 61-92% (Curatio International Foundation & Bemoni Public Union 2017).

Since 2015 within the National Hepatitis C Elimination Program free HCV testing and treatment with highly effective direct-acting antivirals (DAA) have been universally available to all groups of population, including PWID.

There were more than 50,000 individuals enrolled in HCV treatment by the end of 2018 (Hepatitis C Technical Advisory Group 2019).
However, the proportion of PWID among HCV treatment patients is unknown.

Drug related deaths Due to flaws in proper documentation of drug overdose related cases, official data on opioid- related (and other) overdose mortality is virtually nonexistent.

According to the data received from the National Center for Disease Control and Public Health (NCDC), there were 11 fatal overdoses in 2018.

Data were provided in accordance with ICD 10 criteria - X42, X62 and Y12.
Although naloxone remains on the list of prescription medications, the Georgian government has agreed to allow its distribution to high-risk groups via harm reduction services.

In 2016 the GHRN distributed 13,987 ampules of naloxone through its network of low-threshold services (Georgian Harm Reduction Network 2019).

Drug markets Georgia is not a major drug producing country.
Local production is limited to small-scale cultivation of cannabis and kitchen production of opioids and amphetamine type stimulants for personal use.

Dealer-driven illicit supply of traditional drugs has been supplemented in recent years by the internet-based and mobile app-based interactions.

New psychoactive substances seemingly are involved in a remarkable share of these new technology-mediated interactions.

Law enforcement 9 agencies seized 49 different controlled substances in 2018.
Traditionally the largest volume of seizures was on cannabis products.

Drug related legislation Drug use is a criminal offense in Georgia.

First-time illegal drug consumption or possession of a small quantity of drugs for personal use is a misdemeanor offense.

A repeated offense within a year of the first episode results in a criminal liability.

Georgian law does not establish a threshold for small quantities for about three-quarters of substances classified as illicit drugs.
This means that possession of any detectable quantity of those substances, including the residue of such substances in paraphernalia, qualifies as possession of a large amount, triggering criminal liability and a mandatory minimum five year prison sentence.

Possession of more than one gram of those same substances is considered a “particularly large amount” and could result in life imprisonment.
Police have broad powers to stop individuals in the streets and compel them to undergo drug testing, if there are “sufficient grounds,” including police intelligence, for assuming that the individual is under the influence of drugs.

If the person refuses to undergo the test, police can detain him/her for up to 12 hours in a forensics lab.
Drug felony convictions lead to deprivation of the right to operate motor vehicles and to work in certain professions for periods ranging from three to 20 years after release from prison.

Lead by civil society advocacy movements, there have been remarkable changes in law enforcement policy and practices towards liberalization.

Most were prompted by lawsuits filed with the constitutional court.
In response to a 2015 constitutional court decision declaring imprisonment for marijuana possession unconstitutional, parliament amended legislation in July 2017 to remove imprisonment as a penalty for up to 70 grams of cannabis possession.

The 2015 decision prompted other constitutional complaints that challenged current criminal drug policies, particularly regarding recreational drug use.
A November 2017 constitutional court decision argued that it is within an individual’s right to choose how to relax, including through marijuana consumption.

According to the court, unless this action creates any relevant risk or danger to another person, it should not be considered a crime.
Building on this decision, in July 2018, the constitutional court issued another ruling, abolishing all administrative sanctions for marijuana consumption, but it did not deliberate on the issues of purchase or possession of marijuana, which are regulated under the criminal code.

Drug related offences Criminal offences There were 2,928 individuals convicted for drug related offences with 727 (24.8%) individuals imprisoned in 2018.

Almost 9 in 10 of these cases (87.9%) were settled by a plea bargain.
As in previous years the vast majority of drug related criminal charges were related to violation of Art.

273 (repeated use or possession of small amounts) and Art.

260 (possession of more than small amounts) of the Criminal Code of Georgia.

Notably, there has been a remarkable reduction in a number of criminal cases and court proceedings related to drug law violations in recent years.

10 Administrative offences There were 8,650 individuals detained and tested for drug use in 2018.
About 60% (n=4,961) were confirmed to be under the influence of drugs.

There were 4,211 individuals charged for drug use or possession of small amounts of controlled substances.

In 89.9% of cases these individuals were charged with administrative fine.

There has been a significant reduction in incidence of both the number of street drug testing episodes and the number of registered administrative offences over the last few years – see Figure 5.

Figure 5.
Figure 5.

Trends in street drug testing 2006-2018 70000 60000 50000 40000 30000 20000 10000 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Positive 4014 17745 19302 11794 11348 8138 7627 22711 14005 9696 8229 6657 4961 Negative 1286 39255 23727 21498 22244 19040 12373 37485 36860 23372 14176 6518 3022 Coordination mechanisms The Interagency Coordination Council to Combat Drug Abuse was established in 2011.
The council is chaired by the Minister of Justice and is composed of representatives of relevant government agencies.

Representatives of international organizations and civil society organizations are invited as non-voting members.

The Council is responsible for developing and approving drug related strategy and action plans and for coordinating relevant activities.
The National (anti)Drug Strategy was approved in 2013 and was based on four-pillar concept of drug policy (supply reduction, prevention, treatment and harm reduction).

Anti-Drug Action Plans (2014-2015, 2016-2018) have been also developed and approved.

However, there is a lack of clear mechanisms on the monitoring and/or evaluation of these action plans.

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