‘South Asian cocktail’ - the concurrent use of opioids, benzodiazepines and antihistamines among injecting drug users in Nepal and associations with HIV risk behaviour

Abstract

BackgroundData of the Central Bureau of Statistic of Nepal from 2008 show a total of more than 46,000 illegal drug users, out of which 61% are injecting drug users (IDU). An injecting mix of medicines like opioids, benzodiazepines and antihistamines (the so-called South Asian cocktail) was prevalent. Furthermore, it is estimated that about 70,000 people are living with human immunodeficiency virus (HIV). The government of Nepal has started realizing and recognizing drug use and HIV as significant health and social issues. Harm reduction programs such as needle syringe exchange and opioid substitution treatment are being implemented.MethodsThe aim of this study is to obtain specific knowledge on the drug use behaviour and the health status of drug users with a focus on HIV in drug users with concurrent injection of opioids, benzodiazepines and antihistamines. After an initial mapping of Kathmandu Valley, 300 drug users in contact with different treatment and counselling centres were randomly chosen for the interviews. The research questionnaire was designed according to the European Addiction Severity Index (EuropASI) and Maudsley Addiction Profile standards.ResultsNinety-one percent of the respondents are male and 9% female. Mean age is 28.7 years. Ninety-five percent are injecting drug users with a mean of 8.7 years of drug use history. Eighty-six percent are injecting different ‘cocktails’, usually made of buprenorphine, diazepam, promethazine and/or other substances (30-day prevalence). Similarly, 48% use heroin, whereas only 2% take cocaine/crack. Among those tested for HIV (N = 223), 33% are positive (25% of the sample population). Compared to the other drug users (mainly heroin), the cocktail users show a higher HIV infection rate and more co-infections. Furthermore, risk behaviour, as e.g. needle sharing, is much more common among the cocktail users.ConclusionCurrently, the mixture of medicines, opioids, benzodiazepines and antihistamines, is the predominant drug in Nepal; the pharmaceutical drugs needed to prepare the cocktail are less expensive than heroin and relatively easy to acquire. The cocktail users show a higher risk behaviour regarding the transmission of HIV than heroin drug users. It needs to be considered which HIV prevention measures are necessary to target the specific needs of drug users who inject a mixture of opioids, benzodiazepines and antihistamines, since the available services (such as needle syringe exchange) do not seem to cover their specific needs (high percentage of needle sharing).

Nonmedical Use of Antihistaminergic Anxiolytics and Other Prescription Drugs among Persons with Opioid Dependence

“…While there have been reports of nonmedical use of promethazine in combination with opioids from the US [23, 24], India [44], Vietnam [45], and Nepal [46], this, as well as nonmedical use of other prescription antihistamines (hydroxyzine and alimemazine), was uncommon in the present study, in combination with opioids or by itself. However, lifetime medical use of prescription antihistamines was high, reflecting that these drugs are commonly prescribed in Swedish medical care.…”

“I love having benzos after my coke shot”: The use of psychotropic medication among cocaine users in downtown Montreal

“…Earlier studies have examined the use of prescription tranquilizers (benzodiazepines) among people using drugs, but have mostly focused on opiate users (heroin users and methadone maintenance clients) in different parts of the world (Forsyth, Farquhar, Gemmell, Shewan & Davies, 1993;Fountain, Griffiths, Farrell, Gossop & Strang, 1999;Gelkopf, Bleich, Hayward, Bodner & Adelson, 1999;Iguchi, Handelsman, Bickel & Griffith, 1993). More recent studies have explored complex patterns of prescription and street drug co-use that include prescription opioids (PO) and a variety of PM in adolescent populations (Boyd, McCabe, Cranford & Young, 2006;McCabe, & Cranford, 2012;McCabe, West & Boyd, 2013), persons who inject drugs (Courtney, Degenhardt, Bruno, Roxburgh, & Jenkinson, 2004;Johnson, Fibbi, Langer, Silva & Lankenau, 2013;Lankenau et al, 2007;Lankenau, Teti, Silva, Bloom, Harocopos, & Treese, 2012b;Lankenau & Schrager et al, 2012;Ojha, Sigdel, Meyer-Thompson, Oechsler & Verthein, 2014), college students (Quintero, Peterson, & Young, 2006;Quintero, 2009;McCabe, Teter, & Boyd, 2006;Rabiner, Anastopoulos, Costello, Hoyle, McCabe & Swartzwelder, 2009;White, Becker-Blease, & Grace-Bishop, 2006), nightclub goers (Kelly, Welles, Pawson, LeClair & Parsons, 2014;Kurtz, Surratt, Levi-Minzi, & Mooss, 2011) and men who have sex with men (Benotsch, Martin, Koester, Cejka & Luckman, 2011;Kecojevic et al, 2014, Kecojevic, Corliss & Lankenau, 2015Kelly & Parsons, 2013). Only a few studies have focused on PWUC, and those almost exclusively examined PO misuse (Bruneau et al, 2012;Roy, Arruda & Bourgois, 2011;Roy, Richer, Arruda, Vandermeerschen, & Bruneau, 2013).…”

Promethazine use among chronic pain patients

“…Nonmedical use of promethazine has also been reported among heroin injectors in Vietnam who used it to augment an inadequate heroin dose (Clatts et al, 2010) and among individuals that abuse buprenorphine in India (Singh et al, 1992; Sharma and Mattoo, 1999). Recently, it was reported that the “South Asian Cocktail” which contains buprenorphine, diazepam, promethazine, and/or other substances, is the predominant drug of choice in Nepal (Ojha et al, 2014). Nonmedical use of promethazine has also been reported in other areas of the United States, Hong Kong, and India (Wairagkar et al, 1994; Lam et al, 1996; Shek and Lam, 2006; Agnich et al, 2013).…”