New psychoactive substance use as a survival strategy in rural marginalised communities in Hungary

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Research Paper

New psychoactive substance use as a survival strategy in rural marginalised communities in Hungary ⁎

Róbert Csáka, , Judit Szécsib, Sziliva Kassaic, Ferenc Márványkövia, József Ráczc,d,e a

Hungarian Association on Addictions, 46 Izabella street, 1064 Budapest, Hungary Faculty of Social Sciences, Eötvös Loránd University, 1/A Pázmány Péter sétány, 1117 Budapest, Hungary c Institute of Psychology, ELTE Eötvös Loránd University, 1-3 Egyetem tér, 1053 Budapest, Hungary d Faculty of Health Sciences, Department of Addictology, Semmelweis University, 17 Vas street, 1088 Budapest, Hungary e Blue Point Drug Counselling and Outpatient Centre, 25 Gát street, 1095 Budapest, Hungary b

A R T I C LE I N FO

A B S T R A C T

Keywords: New psychoactive substances Survival strategy Marginalised communities Risk environment

Background: New psychoactive substance (NPS) use has become a widespread phenomenon among marginalised communities in Hungary. Since 2010, a growing number of reports in grey literature and anecdotal information among professionals have become available on NPS use among previously unaffected groups, such as people living in rural, socioeconomically deprived communities. In our research, we aimed to explore NPS use among these communities. Methods: We conducted a mixed method research with convergent parallel design. Data collection took place in 2017 in marginalised communities in villages in two regions in Hungary, where 150 questionnaires were recorded and 50 interviews were conducted with current NPS users. Results: According to the survey results, NPS is very easy to access, synthetic cannabinoid receptor agonist (SCRA) are easily bought in marginalised rural communities (79% found SCRA easy to obtain). Both SCRA and synthetic cathinones are used regularly; 57% of SCRA users and 37% of synthetic cathinone users used the respective substance at least once a week in the past 30 days. Besides NPS, sedative use (without prescription) and alcohol consumption are common among the respondents. 17% of the sample has already injected NPS. The overwhelming majority of the respondents rated regular consumption of NPS as “very dangerous” (SCRA: 75%, synthetic cathinones 72%). NPS users have limited knowledge of consequences and the social and health treatment options available. Most themes in the interviews are associated with surviving stress, crisis and anxiety, as well as the wish to escape from insecurity and chaotic life. Positive effects of substance use (community, joy, energy) are rarely present. Conclusion: People who use drugs (PWUD) living in these rural communities face the consequences of the rural risk environment: easy access to NPS, inadequate access to services, poor labour market situation and attributions of marginalised groups, for example disaffiliation. NPS use is not a recreational activity in this population; individuals mainly use NPS to get away from reality, problems, pain, poverty and marginalisation. NPS use is a survival strategy. Effective responses have to address substance use and social integration; we need complex interventions addressing structural factors.

Background New psychoactive substances (NPS) are increasingly seen as a substance disproportionately used in deprived populations (EMCDDA, 2017). NPS use in marginalised, socially disadvantaged, vulnerable groups is a clear trend in the European context. Synthetic cannabinoid receptor agonist (SCRA) use in high risk drug-using populations has been reported in two-thirds of the countries reporting to

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the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA); problematic use of synthetic cathinones has been reported in half of the EMCDDA reporting countries (EMCDDA, 2017). SCRA use has been described in prison populations (Ralphs, Williams, Askew & Norton, 2017), amongst homeless people (MacLeod et al., 2016) and socially vulnerable young people (Blackman & Bradley, 2017). Synthetic cathinones are frequently used by syringe programme populations (Windelinckx, 2015) and NPS injecting has been associated with

Corresponding author.

https://doi.org/10.1016/j.drugpo.2019.102639

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Please cite this article as: Róbert Csák, et al., International Journal of Drug Policy, https://doi.org/10.1016/j.drugpo.2019.102639

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communities could reach. The policy environment of substance use in Hungary became less lenient; in 2013 the Criminal Code was amended, and beside the acquisition and drug trade, illicit drug consumption became punishable (Hungarian National Focal Point, 2014). It is also important to add that the macro-level of social environment is also unfavourable to PWUD in general, but even more so for PWUD living in rural areas. According to the last general population survey on substance use in Hungary (Paksi, Demetrovics, Magi & Felvinczi, 2018) PWUD are the most stigmatised social group in Hungary, and stigmatisation increased further during the past decade. In the general population survey 84% refused to live next door to a substance user (up from 78% in 2007) (Felvinczi, Paksi, Magi & Demetrovics, 2016).

increased risk of hepatitis C infection (McAuley et al., 2019). We used the so-called “risk environment framework” (Rhodes, 2002, 2009; Strathdee et al., 2010) in our analysis. In an oftcited article, Rhodes (2002) has defined risk environment as “the space – whether social or physical – in which a variety of factors interact to increase the chances of drug-related harm”. The risk environment model comprises four ideal types of environment – physical, social, economic and policy environments – and environmental influence on the micro and the macro levels. These different environments represent the immediate and broader context of substance use, for example the streets of the neighbourhood, the substances available (physical environment), peer-group norms, stigmatisation of people who use drugs (PWUD) (social environment), the local labour market, government spending on harm reduction (economic environment), legal consequences of drug use (policy environment). The risk environment framework is an important theoretical tool in drug policy research, as it highlights that some consequences of substance use are shaped by factors that are external to the individual, and drug-related harm is a “product of the social situations and structures in which individuals find themselves” (Rhodes, Singer, Bourgois, Friedman & Strathdee, 2005, p. 1036). This perspective is crucial in understanding substance use in rural setting, where the possibilities and barriers of PWUD might be different from urban areas.

Rural marginalised communities in Hungary Living in rural areas in Hungary could be a disadvantage. People have limited access to the labour market, most of the services of the social and health welfare system are not available locally, and the public transport system is inadequate. Many are of Roma origin, which in itself is often perceived as a disadvantage in the general population in Hungary (Csák, Márványkövi, & Rácz, 2017). These structural characteristics can determine the options and possibilities available to people who live in such rural marginalised communities. In the present paper, we are focusing on the context and motifs of NPS use in rural communities, and in the analysis we drew upon the framework of risk environment (Rhodes, 2002, 2009; Strathdee et al., 2010) to interpret our results. To describe the risk environment to substance use in marginalised rural communities, we briefly show the spatial inequalities in the health and social welfare system in Hungary, the past changes in the drug market, and the characteristics of the social environment regarding substance use. From the perspective of risk environment, PWUD in marginalised rural communities in Hungary live in an unfavourable physical environment. On the micro-environmental level, spatial inequalities affect them because most of the services of the social and health welfare system are not accessible (Csák, Márványkövi, & Rácz, 2017). In the two regions where the research was conducted (see the methods section below), all substance use-related services are situated in the major cities of the regions and are practically inaccessible for those who live in villages. The distribution of the healthcare system is also unequal. Although general practitioner service has national coverage, general practitioners are typically available for only a few hours a week in small villages. The coverage of the social welfare system shows a similar pattern: family support and child welfare services (the basic level social service in Hungary) are available in every village, but services capable of addressing more complex issues are available only in the cities (Csák, Márványkövi, & Rácz, 2017). Another important element of the physical risk environment is the drug market. In the past years, NPS use has become a widespread phenomenon among marginalised communities in Hungary. Since 2010, when NPS became widely available in the Hungarian drug market (Hungarian National Focal Point, 2010, p. 30), a growing number of reports in grey literature and anecdotal information among professionals have become available on NPS use among previously unaffected groups: people living in rural, socioeconomically deprived communities. The Roma population and marginalised communities living in rural areas are two intertwined topics in Hungary. According to the latest census of Hungary, Roma people are more likely to live in villages: 50,4% of the Roma population live in villages, while only 29% of the general population live in rural areas, with Roma people being overrepresented in economically deprived regions of Hungary (Pénzes, Tátrai & Pásztor, 2018). In the aforementioned general population survey, Roma was the fourth highly marginalised group in Hungary after PWUD, alcoholics and formerly incarcerated

NPS use in Hungary The NPS phenomena first appeared in Hungary in 2010, and as political transitions could influence the risk environment (Rhodes & Simic, 2005), transitions in the local drug market also could have an effect on the risks PWUD face (Strathdee et al., 2010). This transition from traditional substances to NPS among people who inject drugs (PWID) in urban marginalised communities is well documented in the literature (Kapitány-Fövény & Rácz, 2018; Rácz, Csák & Lisznyai, 2015). Before the emergence of NPS, heroin and amphetamine were the two substances that the overwhelming majority of PWIDs injected in Hungary (Péterfi, Tarján, Horváth, Csesztregi & Nyírády, 2014). In 2010, the availability and pureness of heroin deteriorated significantly (Hungarian National Focal Point, 2011), while NPS were easily accessible and had high active compound content. These were the key environmental factors that interplayed in this transition (Csák, Demetrovics & Rácz, 2013; Rácz et al., 2015). Once NPS became available in the drug market, the percentage of heroin users started to drop, but gradually amphetamines were replaced by NPS as well (Rácz et al., 2016). During this period, the health risks of injecting increased substantially. The results of the national HIV/HBV/HCV seroprevalence study of PWID, carried out in low-threshold services in urban areas, showed that the prevalence of HCV among PWID doubled between 2011 and 2014. In 2014, the prevalence of HCV among PWID was 48,8% in the country (up from 24,0% in 2011), and 60,9% in the capital (34,2% in 2011) (Hungarian National Focal Point, 2016). This increase could be partly attributed to these new substances, as NPS have been associated with a higher number of daily injecting episodes (Tarján et al., 2015). On the other hand, there were unfavourable changes in the political and economic environment: national spending on substance use related services decreased from EUR 3,8 million in 2009 to EUR 0,4 million in 2012 (Hungarian National Focal Point, 2010, 2013); the coverage of needle exchange programmes (NEPs) dropped significantly; the number of syringes distributed per PWID a year, which is the WHO recommended NEP coverage indicator (WHO, UNODC, & UNAIDS, 2012) decreased from 114 per year in 2011 to 39 in 2014 (Gyarmathy et al., 2016). These changes in the available financial resources also affected the capacities of service providers in other substance use-related services, including non-governmental organisations providing harm reduction, prevention and treatment services in small cities, which further decreased the coverage of services PWUD in marginalised 2

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The qualitative strand focused on the respondents’ past and present substance use, the characteristics and patterns of substance use in the village, motifs of use and the risks and consequences of substance use according to the perceptions of the interviewees. Interviewers conducted semi-structured interviews using a guide with the above-mentioned topics. Interviews were audio-recorded and transcribed verbatim. Interviews were analysed using thematic analysis (Braun & Clarke, 2006). One of the authors coded 10 interviews inductively, where primary codes and topics emerged. Based on the primary codes, the other 40 interviews were coded by a group of four researchers who reached consensus regarding the patterns of codes and organised the topics into comprehensive themes. We checked the validity of the codes and topics by rereading the interviews. Ethical approval for this study was obtained from Research Ethics Committee of Eötvös Loránd University Faculty of Education and Psychology (approval number: 2017/175).

(Felvinczi et al., 2016). Thus, two of the most stigmatised social groups in Hungary are intertwined in the phenomena of substance use in marginalised rural communities. Although NPS use is a well-explored phenomenon in Hungary, scientific evidence on NPS use in Hungarian rural communities are scarce (Kapitány-Fövény & Rácz, 2018), thus, we aimed to explore NPS use among these social groups further. Our goal was to examine the structural characteristics and determinants of the rural risk environment and define attributes of the different environment types that can influence substance use in this setting. Methods Data collection took place between June and September 2017. 149 questionnaires were recorded and 50 semi-structured interviews were conducted in socioeconomically deprived communities in rural areas, equally distributed in two regions: Northern Hungary (NH) and South Transdanubia (ST). To identify socioeconomically deprived communities, we used the indicator of the Hungarian Central Statistical Office: socioeconomically deprived is the area where the proportion of those with primary education or less, and those without regular labour income, are higher than 50% (Ministry of Human Capacities, 2015). We chose the two regions with the lowest GDP in Hungary in 2017 (NH: EUR 9734 million, ST: EUR 7478 million, Eurostat, 2019); both regions are under the 50% of the EU average (NH: 46%, ST: 45%,% Eurostat, 2019). The data were collected in 22 villages (NH:18, ST: 4) with less than 5000 inhabitants. We conducted mixed-method research with convergent parallel design (Creswell & Plano Clark, 2011), implementing the quantitative and qualitative strands concurrently, analysing the two data sets independently and integrating them at the overall interpretation of the data. Interviews and questionnaires were collected with privileged access interviewers method (Griffiths, Gossop, Powis & Strang, 1993). Interviewers were experienced social workers who worked in street outreach and harm reduction services in the regions. PWUD using these services were key informants; interviewers identified villages with NPS use and potential respondents through conversations with these informants. Once interviewers arrived at a selected village, they started recruiting for the survey with the PWUD they had been referred to and asked those for further referrals to villages and respondents. In a village without a referral, interviewers followed the protocol of recruiting in the first house in the socioeconomically deprived area of the settlement and asking the first respondent for further referral to other villages and respondents. When recruiting was not successful, or when the interviewers could not get further referrals, they continued in the next village and started the recruiting process there. Every second respondent was asked to participate in the qualitative strand. We used convenience sampling. The inclusion criteria for the participants were: willingness to participate, being 18 years old or older, self-reported NPS use in the last four weeks, and living in a socioeconomically deprived area in the villages. 75% of those who met the inclusion criteria participated in the survey and the response rate was 66% for the interview. All participants received 1000HUF (approximately 3 EUR) as a financial compensation for completing the survey, and the same amount for participating in the interview. The interviewers administered the questionnaire by paper and pencil. The main topics of the questionnaire were the prevalence of substances, the prevalence of injecting use, the perceived availability of substances and access to services. In the questionnaire, we recorded NPS use in two general categories, synthetic cathinones and SCRA, using a short definition and common street names of substances for each category. Questionnaires were analysed with SPSS. Descriptive statistics were calculated to explore prevalence rates, and chi-square analyses were calculated to compare differences by categorical and independent factors.

Results Survey results The survey sample was dominantly male; the mean age was 25,8 years; the youngest participant was 18 years old, and the oldest was 67 years old. The participants have an unfavourable labour market position, they had low educational attainment: somewhat more than three quarters had lower than secondary education, and in the past month only 26,8% had income from full-time employment. An additional 7% had income from part-time employment (Table 1). According to the survey results, access to NPS is very easy. SCRA were the most accessible substances in the marginalised communities: 79,2% (n = 118) found it easy (answered “fairly easy” or “very easy” to the question “How difficult would it be for you to buy it if you wanted to?”) to obtain it (Fig. 1). For most of the respondents (56,4%, n = 84) synthetic cathinones were also easy to access. However, both sedatives without a doctor's prescription and inhalants were more accessible to the respondents. “Classic” illegal drugs like cannabis or amphetamines were the least accessible substances for the respondents (36,9% n = 55; 33,6% n = 50, respectively). Nevertheless, there were differences between the two regions. In the ST region, the majority could easily buy both cannabis (60,0% n = 45) and amphetamine (53,3% n = 40); In the NH region only 10 respondents (13,5%) said that it was easy to buy cannabis and amphetamine (p < 0.0001 for both substance). In our NPS user sample, the lifetime prevalence (LTP) of legal and “classic” illegal substances were relatively high. LTP of cannabis was 82,4%, amphetamine was 66,9%, these were the most popular “classic” illegal substances among the respondents. Prescription drugs dominated among the legal substances with tranquilisers and sedatives without a doctor's prescription on the top (LTP: 72,3%) followed by the combined use of alcohol and prescription drugs (LTP: 63,1%). Beside NPS, alcohol consumption was also common among the respondents. Table 1 Characteristics of the survey sample (N = 149). Demographics Gender (n = 149) Male Female Age (n = 147) 19 years or under 20–24 years 25–34 years 35 years or above Educational attainment (n = 145) Primary or less Unfinished secondary Finished secondary

3

N (%)

122 (81,9%) 27 (18,1%) 31 56 40 20

(21,1%) (38,1%) (27,2%) (13,6%)

88 (60,7%) 22 (15,2%) 35 (24,1%)

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Fig. 1. Proportion of those who found it “fairly easy” or “very easy” to obtain the given substance (N = 149).

survey sample: they were predominantly male, the youngest participant was 18 years old, and the oldest was 53 years old (Table 2). During the thematic analysis six main themes were identified in the interviews; acquisition, setting of substance use, reasons for consumption, experience, information (misconceptions), quitting (see: Table 3).

While SCRA were used daily by 25,7%, the proportion of those who drank spirits/liquor or beer almost every day (12,9%, 11,5% respectively) was higher than the proportion of daily synthetic cathinone users (7,9%). Injecting had a lifetime prevalence of 16,8% among the respondents (Fig. 2). There is a distinct pattern in the combined use of NPS: using SCRA and using both SCRA and synthetic cathinones are the typical form of NPS use, while those who used only synthetic cathinones during the last 30 days were a minority among the respondents. We could differentiate between the two regions in this regard (p = 0,050): in the northern region the respondents were more likely to use only SCRA; in the southern region, the majority used both types of NPS (Fig. 3). The overwhelming majority of the respondents rated regular consumption of NPS as “very dangerous”. The NPS users sampled rated regular NPS use as the most dangerous form of substance use: in their opinion, it is more dangerous than smoking 20 or more cigarettes a day, drinking 4–5 units of alcohol almost every day or using herbal cannabis regularly. While 37–43% found the former substance use patterns as a serious risk, almost three-quarters of the sample thought that the substances they regularly use are hazardous for them (Fig. 4). We asked about the previous year's use of several types of social and health services in the questionnaire; we did not restrict the responses to substance use-related reasons. Respondents had limited access to social and health services, with the general practitioner being the most accessible service (see: Fig. 5). The majority did not meet a social worker in the past 12 months, and only a quarter of them were in the local family and child welfare service. The proportion of PWUD who used a substance use-related service was the smallest; this was the least accessible intervention for the respondents.

Acquisition This theme covers how the participants could get the substances, the location of the dealer, the availability of substances (physical environment), and the price (economic environment). Participants reported that NPS are easily available for them; they mostly bought the drugs from friends or well-known dealers. The respondents typically bought NPS locally, but sometimes they had to travel to the closest city. The price of one packet (approx. 0,6–0,8 g) of SCRA in herbal form (SCRA powder is sprayed to dry herbs by the dealers and sold in herbal form) is about 500–1000 HUF (1,5–3 EUR), synthetic cathinone costs more, 1000–2000 HUF/gram (3–6 EUR). “Classic” illegal substances are less accessible to PWUD because those substances are more expensive. Interviewees frequently compared the price of SCRA to cannabis, which usually costs 2500–3000 HUF/gram (7,5–10 EUR). It is worthwhile adding that NPS and SCRA, in particular, could be cheaper than alcohol; for the price of one packet of SCRA, participants could get only 3–5 bottles of light beer. In these socioeconomically deprived communities, a person's income is approximately 20.000–40.000 HUF (60–120 EUR) per month; thus, the price of NPS could be a strong factor. In this theme, the economic and physical environment play together to facilitate NPS use: PWUD have limited financial resources, so they buy the cheapest drug available locally. “I like the real weed more, but if you do not have the money… that is expensive for real, because it's 2500, and they give you so little. So we get bio [SCRA] instead, you can get the same amount for 1000.” (27, female, ST region)

Qualitative results The gender distribution of the interviewees was similar to the

Fig. 2. Frequency of NPS and alcohol use in the last 30 days among those who used it in the past 12 months. 4

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Fig. 3. Combined use of NPS in the last 30 days by region.

blackish.” (27, male, ST region) Setting of substance use

Reasons for consumption

Although this theme is about the immediate physical environment where the substance use occurs, it is deeply linked to the social environment. According to the interviews, the most prevalent setting for NPS use is in hiding and alone, and the reason is the strong stigmatisation of substance use in those communities, with the strongest stigma linked to injecting use. Thus, the most common setting of substance use was an abandoned building, hiding, and in small groups (when people were using NPS together). Participants rarely used NPS in public spaces, and substance use in a party setting was mentioned as something they had done in the past.

According to the interviews, NPS use was not a recreational activity in this population; there were some positive elements in using NPS, there were “pleasure” and “community” themes in the interviews (right column of Table 3), but these are less frequent, less common themes. Three different motives for substance use appeared in the interviews, each linked with different set of substances: recreational, productive, and escapist. When the interviewees talked about recreational substance use, any legal or illegal substance could appear in their stories, and the aim of substance use was to get new experiences and connect with new social circles. This was the motif where something beyond surviving could appear in the narratives. Productive substance use was typically connected to prescription drugs (tranquilizers, e.g., clonazepam) and alcohol use, and the aim of the substance use was to be able to manage everyday tasks successfully. When the interviewees talked about tranquilisers and alcohol, they typically did not mention any effects; these were only the means to be able to manage everyday life and carry out routine tasks. Escapist substance use was typically connected to NPS. This was the most prevalent motif in the interviews and the most common reason for using a substance among the interviewees. Most of the participants used the drugs to survive stress, crisis and escape from boredom, poverty, psychological problems and the unpredictable life of marginalised people.

“They hide to smoke or shoot up, they go to places where others won't see it… we try to hide from the world.” (32, male, ST region) Because participants are often using NPS because they want to be knocked out, they prefer to use it in abandoned places where no one could see them. In this setting, PWUD have different practices to mitigate drug-related harm. For example: “You have to spill milk or sour cream into his mouth very quickly… it mitigates the…you know. He vomits and ten minutes later he is fine again.” (39, male, NH region) In other cases, participants prefer to use NPS in a friend's apartment, because they could help each other with the unwanted drug-related symptoms. Sometimes, participants will call an ambulance, too. “Last time we had to call ambulance because he became aggressive, he attacked the paramedic, he was choking and his head became

“To be honest, they don't have any money, they don't have a proper job,

Fig. 4. Perceived risks of substances and the frequency of use, % (N = 149). 5

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Fig. 5. Proportion of those, who used the given service in the past 12 months, % (N = 149).

“When I wake up, I take the children to school. There is no opportunity to work. If I had a chance, I would work. They don't hire me even at the [municipal] office… That's all, I have one pig and one duck I look after them.” (32, male, NH region)

Table 2 Characteristics of the interviewees (N = 50). Demographics Gender Male Female Age 19 years or under 20–24 years 25–34 years 35 years or above Region Northern Hungary South Transdanubia

N (%)

45 (90%) 5 (10%)

Experiences

4 (8%) 19 (38%) 18 (36%) 9 (18%)

Positive experiences of NPS use (community, joy, being energised) were present only in a handful of interviews, though euphoria was never mentioned in the narratives. The experience of NPS use was overwhelmingly negative: serious, unpredictable, uncontrollable effects, hallucinations, anxiety, aggression and paranoid thoughts. These often led to serious negative physical consequences, even to losing consciousness. Calling an ambulance occurred many times in the interviews, though no other health or social service was present in the respondents’ stories.

25 (50%) 25 (50%)

their family situation is very bad, maybe it was good once but then it went downhill… They have no prospects in life, so they rather do drugs, get high, chill, piss themselves and that's all.” (21, male, ST region).

“I was lucky. There were others, hiding under the window, dreading the police, hallucinating and so on. […] If someone got paranoid, could stay that way, and end up in the asylum. Not everyone can control it.” (31, female, NH region)

“I need the weed [SCRA], or I become stressed. And I always need pills… No way I can manage without them. Pills are always in me. I can't exist without them” (43, male, ST region).

“When someone can't handle it, foaming in the mouth starts. Spits white, and vomit. So, after vomiting, you have to puff some [SCRA], and you will feel better.” (32, male, ST region)

The dominance of the latter two motifs in the interviews could be linked to the rural environment, as PWUD living in these deprived rural communities have limited access to jobs, services and transportation. This lack of opportunities compels them to use every means at their disposal, including legal and illegal substances.

Calmness and tranquillity can be an example of how experiences could have a different perspective and meaning in the context of escapist substance use in a rural, marginalised community. While

Table 3 Composition of main themes (bold) and themes identified in the interviews. Functional Acquisition - Closed network, locally Setting of substance use - “Closed”, private locations - Alone, hiding Reason for consumption - Boredom – escape - Psychological problems – escape - Poverty – escape Experiences - Unpredictable, uncontrollable - Negative experiences (extreme negative experiences: panic, aggression, paranoia, hallucination) - Prescription drugs are a must to survive everyday life - Deaths/resuscitation/feeling sick; calling an ambulance Information (misconceptions) - Misconceptions, banalisation Quit substance use - Ambivalent, rather not - Fear of stigmatisation (use becomes public)

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Recreational

Setting of substance use - Public places - Together, communal Reason for consumption - Desire to belong to a community - (To have fun: in the past)

Experience - Good: cheer up, energised

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other drugs, these rural areas can be characterised by inadequate coverage of social and healthcare services; the general practitioner was the only healthcare service that the majority could access. The overwhelming majority had no contact with a substance use-related intervention in the past 12 months. Although all respondents lived in a socioeconomically deprived community, the majority did not meet a social worker throughout the last year and only 25% were in the local family and child welfare service. Less access to health care and drug treatment seems to be an intrinsic characteristic in rural areas, it is also considered a barrier for PWUD to enter treatment in rural areas in the USA (Cucciare et al., 2018; Moody, Satterwhite & Bickel, 2017). The inadequate coverage of these services could be the most profound disadvantage of the rural environment, and all type of risk environment interact. The physical environment could describe the geographic inequalities (services are located in the city, the transportation is expensive and/or insufficient), the macro-economic environment could highlight the problems in the funding of the healthcare and social welfare system, and the policy environment could represent all the public policies and regulations that determine the coverage of these services. The unfavourable labour market situation of PWUD living in these rural communities was reflected in the income of the NPS users; only third of our sample had income from part-time or full-time employment. Their low income and the lack of job opportunities show how the economic environment can increase the risk of substance use by restricting the choices PWID make. Respondents clearly regarded regular NPS use as the most dangerous form of substance use: almost threequarters of the sample rated regular consumption of NPS as “very dangerous”. Interviewees also described the experience of NPS use with serious, unpredictable, negative effects, such as hallucinations, anxiety, aggression and paranoid thoughts. However, they could hardly afford anything else, even if they wanted to use a less harmful substance with fewer health risks. This contradiction was clearly reflected in the acquisition theme of the interviews: interviewees frequently compared the price of SCRA to cannabis, though cannabis was not a real option for them due to limited financial resources. The rural risk environment could be a good example of the inseparability of different levels of environmental influence (Rhodes et al., 2005). The characteristics of the physical and the economic environments described above indicate that participants are in the process of disaffiliation (Castel, 2000). They lack the potential to mobilise financial resources but are also unable to mobilise the resources the welfare system could offer. Without any interaction with other groups, participants lack the potential to mobilise relationships outside their community. This dissociation of the social bond (Castel, 2000) is further strengthened by the social environment, as PWUD are the most excluded social group in Hungary (Felvinczi, Paksi, Magi & Demetrovics, 2015). The disaffiliation and stigmatisation of PWUD was also present in the interviews, as participants had no or negative experiences about professional treatment; the most common setting of substance use was hiding in abandoned buildings. Furthermore, living in a rural, socioeconomically deprived community in Hungary is characterised by extreme uncertainty (Kozma et al., 2010), where planning is typically unfeasible. This complex situation is transformed and represented in the interviews as a reason for use: the majority of themes about the use of NPS were about the functional use of substances: individuals mainly use NPS to escape reality, problems, pain, poverty and segregation (see left column of Table 3), surviving the stress associated with hopelessness and uncertainty, and escape from poverty and boredom stemming from the lack of opportunities. Participants’ practical experiences reflect the same environmental characteristic through the context of escapist substance use: NPS allow participants to enjoy calm and tranquillity without the struggles and stress of everyday life. To understand this type of practice, we should appreciate that “risks” might be seen differently by PWUD themselves, and rationality

euphoria did not appear in the interviews when the interviewees talked about the effect of the NPS, calmness and tranquillity on the other hand, were amongst the attributes the interviewees connected to NPS use. These narratives in the interviews suggested that NPS use defined a time when participants can be relieved from stress and anxiety. Calmness and tranquillity became a goal that can be achieved through substance use. “One can enjoy a calm world, tranquillity peacefulness, happiness. That is why we use it, or at least I do. […] In that moment I can forget everything, I'm alone, just myself in my own quietness […] It [NPS] makes me feel good, I'm calm, I'm not aggressive.” (23, male, ST region) Information (misconceptions) The interviewees barely had adequate information on the effects of NPS. Most of their knowledge came from fellow substance users, whose information was unreliable. In fact, little information is available about the active compound of NPS because the drugs are constantly changing. Insufficient information often leads to misconceptions and understatement of risks. “When you smoke, your blood sugar level falls and you have to eat chocolate and drink lemonade” (22, male, ST region). Although the stigmatisation of substance use (social environment) could prevent PWUD in getting appropriate information on the effect of NPS, the lack of coverage of substance use-related services, the poor access to health and social services could all contribute to the barriers to getting reliable information. Quit substance use The willingness of quit using substances rarely appeared in the accounts. Participants think they could stop using any time but do not want to. Participants have no or negative experiences about professional treatment; if they need help, they would ask fellow users. Most of the participants knew how they could ask for help and where to find professionals (psychiatrists, drug ambulance, hospital), although these sources of help are in other towns. Participants think will power is the most necessary quality for quitting drug use. There were two main reasons to quit using drugs mentioned in the interviews; one was the desire to live a normal life “like others do”, the other reason were serious health consequences of NPS use. “I am just started to think about it [quitting], I have six children, I am 30 years old, I shouldn't do it. It is not ok that my children see it. It was enough. My children shouldn't grow up like this, with their father high. They should grow up normally” (32, male, NH region). Participants reported only negative experiences about professional treatment, if they need help they would ask their peers. Discussion The risk environment is a product of interplay (Rhodes et al., 2005) where different levels and types of environments are entwined; thus we will try to systematically identify the four types of environments in our findings, and grasp the interactions between the physical, economic, policy and social domains. From the perspective of physical environment, it is important that the results of our research confirmed that NPS are easily accessible in Hungarian rural areas. The majority of the respondents could buy SCRA easily, while traditional substances (cannabis and amphetamines) were the least accessible substances. We learned from the interviews that participants usually buy NPS locally, so there is a working drug market in the immediate physical environment of these communities, where NPS are the core products. In contrast to the availability of NPS and 7

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rather a tool in their survival strategy; individuals mainly use NPS to get away from reality, problems, pain, poverty, and marginalisation. Being a substance user in a socioeconomically deprived community in a rural area is a position where physical, economic, social and policy disadvantages are intertwined and increase the risks of substance use. The risk environment framework (Rhodes, 2002; Strathdee et al., 2010) highlights that interventions addressing addiction and substance use alone might not be effective, we need complex interventions addressing structural factors. One of the structural factors that should be addressed is the inadequate coverage of health and social services, as the access to these services could be key in rural areas (Moody et al., 2017). Introducing mobile harm reduction services, outreach programs and peer-based interventions could improve the situation of rural PWUD substantially. Nevertheless, already available services could also play an important role. Since accessing healthcare in outpatient setting is associated with reductions in substance use over time among rural PWID (Cucciare et al., 2018), general practitioners could be also considered among the key interventions as the most accessible service among the respondents. Programmes focusing on social integration and social inequalities should also be implemented, as PWUD in rural marginalised communities use NPS to survive and escape poverty, hopelessness, and the struggles of their everyday life. In addition to long-term and countrylevel policies on social inequalities (e.g. programmes addressing inequalities in education, active labour market policies), community-level environmental interventions should be also considered. We could draw on the experiences of Housing First programmes in Portugal, an intervention that aims to improve participants’ access to resources and community integration through addressing the structural causes of homelessness (Greenwood et al., 2019; Ornelas, Martins, Zilhão, & Duarte, 2014). Our findings show that the desire to live a normal life “like others do” was one of the main reasons why research participants would quit using drugs. Although the evidence is not conclusive on substance use outcomes of Housing First programmes (WoodhallMelnik & Dunn, 2016), and additional support might be needed to reduce substance use (Kirst, Zerger, Misir, Hwang & Stergiopoulos, 2015), based on our interviews, Housing First programmes may nevertheless provide a strong base. In summary, substance use in rural areas is a complex problem, where structural factors influence the practice and consequences of substance use. Implementing complex interventions aiming at socialenvironmental factors might be more effective than interventions focusing on individual behaviour change and the individual risks of substance use.

could be situationally dependent and socially constructed (Rhodes, 1997). As Bourdieu wrote, the “rational” habitus is shaped by the “economic and cultural capital required in order to seize the “potential opportunities” (Bourdieu, 1990, p. 64). For those living in a socioeconomically deprived community with limited resources and an uncertain future, substance use could be a rational practice and a form of “rational” habitus shaped by their opportunities. In summary, NPS users in marginalised rural communities live in socioeconomically deprived areas where they do not have proper access to the health and social welfare system, do not have access to substance use-related services, but can access NPS and tranquilisers. Outside their communities, PWUD would face stigma and social exclusion because of their substance use and often their Roma origin. In these circumstances, the functional use of NPS and other substances to experience calmness and tranquillity could be a rational strategy that could help them survive in everyday situations that are shaped by an uncertain future. Limitations of the study Several limitations should be considered when interpreting these results. One limitation is that we were unable to ask the ethnicity of the respondents, and therefore we do not exactly know the ethnic (Roma vs. non-Roma) composition of the sample. The reason for this is that in Hungary ethnicity is sensitive personal information, and can only be recorded under very specific circumstances controlled by law. Our research was funded by the Hungarian Ministry of Human Capacities, so it would not be appropriate to record information about ethnicity. However according to the interviewers' assessment, almost all of our interviewees and survey respondents were of Roma origin. The research was exploratory research, where we aimed at a population that has not been studied before and does not have connections to substance use-related services. Thus, we did not have any information on the characteristics of the population. We used privileged access and convenience sampling to reach this hidden population, but that decision could affect the sample: participants who have acquaintances in cities might be more likely to be included as we used privileged access method and the sampling started with PWUD using harm reduction services in cities. Since the convenience sampling, we did not include people who did not want to disclose their substance use. As the stigmatisation of substance use is strong in these communities, this is a serious limitation that we tried to overcome by including respondents’ referrals in the sampling process. The sample is not random and may not accurately reflect the PWUD in marginalised communities. The interviewers were familiar with the culture and the language participants used, as they were social workers working with the target group for several years in the region where they conducted the interviews. We followed a reflexive approach, and as such we reflected on our own preconceptions and impressions during the preparation and the implementation of the study. The interviews were analysed by all authors and aiming for consensus among them also decreased the personal bias during the coding process. Because the interpretation of the interview data was restricted to the study population, the interpretation process cannot be considered objective. However, our interview analysis achieves credibility (Thomas & Magilvy, 2011) through allowing others to recognise the pattern of these experiences through the accounts of our research participants. Data triangulation (questionnaire, interview, and literature) also contribute to the credibility of the qualitative results of the study.

Conflict of Interest Statement None. Acknowledgements The research in this paper was funded by the Secretary of social inclusion at the Hungarian Ministry of Human Capacities. We would like to thank to Ákos Topolánszky, member of the presidency of European Economic and Social Committee, for raising the awareness related to the phenomenon of rural substance use in Hungary and working relentlessly on keeping this issue on the agenda of decision makers.

Implications and conclusion

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