The oral health of heroin drug users: case study in Bosnia and Herzegovina

Injection drug use (IDU) is a major public health problem, and has serious consequences on the health of drug users including HIV/AIDS, hepatitis B, hepatitis C, tuberculosis, accidental overdose, and anesthesia complications [1–3]. In addition, negative effects are manifested in health care delivery such as unavailability of health services or avoidance and resist by health care providers, and in the community in terms of social exclusion [4].

There are only a small number of published papers on the oral health of injection drug users (IDUs), although dental and oral hygiene problems are common in this population [5–7]. Oral health problems and the appearance of dental disease among IDUs are caused by their lifestyle. Lifestyle factors which have been associated with oral health problems are alcohol and tobacco use, poor nutrition, irregular eating habits, and poor personal hygiene [3, 7, 8]. Tobacco smoking and drinking causes both separate and interactive periodontal disease, pre-cancerous conditions and oral cancer [6]. Alcohol and heroin (and other opioids) are xerostomic and reduce saliva production which may lead to the development of caries and periodontitis [5–8]. Opiates suppress pain which increases pain tolerance among IDUs and consequently they visit the dentist less frequently [9, 10].

Bosnia and Herzegovina is on the central route of Balkan drug trafficking, which is known as the “drug road”. It is used by organized criminal groups to transfer a variety of illegal drugs, including heroin, into and out of Europe [11]. Bosnia and Herzegovina should be viewed in the context of the post-war period, with socioeconomic and demographic changes, growing poverty, and increased unemployment. This situation creates conditions where there is a higher risk of developing problems with drug use and possible health consequences (e.g. HIV/AIDS and other blood-borne and sexually transmitted infections).

Several surveys on drug use were carried out in Bosnia and Herzegovina up to 2007, however, these data were not comparable with European research data and their methodology standards [11]. During this period and particularly later, studies were conducted in children [12] and populations whose behaviour exposed them to a higher risk of HIV infection [13, 14]. Bosnia and Herzegovina has an inappropriate legal framework, and regulations as well as weak law enforcement. There is a lack of treatment centers for drug addiction, an insufficient number of professionals, and a lack of technology to fight against drug use [11]. Considering this situation, research into the oral health of IDUs has not been conducted in Bosnia and Herzegovina, and in many other countries such research is rare [5, 6].

It is known that the oral health of IDUs is complicated by other factors, including socioeconomic factors, as IDUs spend more and more time and energy obtaining and using the drug. Bad oral health may be related to lifestyle habits among IDUs as they are a socially deprived group and often invisible with regard to health and social services [3]. The aim of this study was to examine the relations between socioeconomic factors, drug use, and oral hygiene habits with regard to the oral health status of heroin drug users.

In total, 519 heroin IDUs with an average age of 28.80 ± 6.96 years were interviewed. The age of the participants ranged from 17 to 53 years. Almost two thirds of participants were single (303, 58.4%). Most had secondary education (348, 67.1%) or primary education (134, 25.8%), while 12 (2.3%) had college or faculty education. Twenty-five (4.8%) participants had no education. Most of the participants were unemployed (453, 87.3%). Eighty percent of participants lived in their own apartment/house or parents’ house. The average duration of drug use was 5.69 ± 5.06 years (range, 0–33 years), and the average frequency of drug injection in the last month was 5.43 ± 2.09 (range, 1–9). Only 39 (7.5%) participants had regular dental checkups. More than half of the participants (273, 52.6%) visited the dentist on a yearly basis, 101 (19.5%) once a year, 61 (11.8%) twice a year, and 113 (21.8%) three or more times a year. Participants preferred to visit the private dental sector than the public dental sector (39.3% vs. 24.9%, respectively). Both sectors were used by 79 (15.2%) of participants.

In a sample of 519 heroin IDUs in Sarajevo, Banja Luka and Zenica in Bosnia and Herzegovina, we examined the relations between socioeconomic factors, drug use habits, and oral hygiene habits in participants with good and bad oral health.

Our results showed that older participants and those with a longer duration of drug use had a higher risk of developing bad oral health which is in accordance with previous research [5, 18]. In addition, participants with part-time employment, unemployed and those who did not go for regular dental checkups had a 3-fold higher risk of developing bad oral health than participants with full–time jobs and who attended regular dental checkups. Researchers have shown that poor dental health among IDUs was related to untreated oral health problems. IDUs did not seek formal treatment except in emergency situations, took extra drugs for toothache, or ignored oral problems until they were placed in rehabilitation facilities [3, 6, 19, 20]. In Bosnia and Herzegovina, there are no specialized treatment centers for drug users. Community mental health centers across the country provide outpatient treatment and counselling for drug users who are not their only target group [21]. Dental health problems could be resolved in public or private institutions; however, IDUs did not utilize services enough from neither of these two institutions. The reason could be to keep secret of their addiction.

The research conducted on 58 drug use participants at the Native American Health Centre in San Francisco showed that, even they received a voucher for a dental examination, they did not make an appointment for it [7]. The use of dental care facilities may depend on factors such as intensity of drug use, public versus private care, treatment experience, low self-esteem and dental anxiety [3, 22].The researcher’s assumption was that IDUs may need different type of dental care services. Dental care could be provided as integral part of treatment addiction in rehabilitations centers. Dental professionals in public or private health centers should have enough knowledge to recognize the symptoms of drug abuse and provide the best possible dental treatment. This could lead to access to dental services on an equitable basis and more open communication between dentist and patient. Also, to develop adequate strategies to prevent and manage dental diseases for this population group should be challenge for public health professionals [7, 23].

In 2007, Bosnia and Herzegovina characterized by a very high unemployment rate of 47.24%, statistically demonstrated increased income, however, at the same time food prices increased compared with 2006 [21]. In addition, national data showed that oral health in the general population and children was unsatisfactory and preventive measures among children in the first grade of primary school have been carried out since 2005. More than half of the total dental morbidity are diseases of the adult population (55%). In 2007 in this age group occurred change of the first two top diseases. So after many years diseases of the dental pulp and periapical tissues (K04) was on the first place (35.0%), while dental caries (K02) was in second place (33.0%) [21]. According to the data oral health in Bosnia and Herzegovina was the worst in the Europe [24] Regardless of the poor socioeconomic conditions in Bosnia and Herzegovina, heroin abusers not only have bad general health, but they also have significantly poorer oral health and oral hygiene practices. The situation in Bosnia and Herzegovina, in addition to poor living conditions, is complicated by the availability of drugs and their street price. The street price of heroin per gram varied from city to city, and is five time more expensive in Sarajevo than in Banja Luka (3 EUR) [25].

In this survey, participants who brushed their teeth more often (once or twice a day) had a reduced risk of developing bad oral health. The reason for this could be better living conditions as well as better personal hygiene (live in own or parents’ house). Infrequent tooth brushing is a common behaviour among drug users. Research found that IDUs brush their teeth less than once a day and do not accept the responsibility and obligations of dental treatment [3, 7]. In our research, participants with a higher level of education had a lower risk of developing bad oral health which could be related to better knowledge regarding health.

Although Bosnia and Herzegovina has an HIV/AIDS infection rate of 0.01% and has a low HIV prevalence [26], solving the problems related to drug abuse is an important public health task. The country did not face the problem of drug use until 2007. There were only few centers for drug addiction treatment, including those which provide substitute therapy. There was lack or no continuous prevention programme at schools and in the community. The adopted state drug strategy was not implemented. Also, information system on drugs was still under development. The research on the biological and behavioural survey among injection drug users in Sarajevo, Banja Luka and Zenica provided evidence for further policy decisions and services development for IDUs. The poor dental health in this target group indicated the need for more collaboration within the community, e.g. between the social and dental health care sectors which should develop strategies to prevent and manage dental disease in this population. Another survey on IDUs using the RDS method was carried out in 2009, and progress was made when the ‘Protocol on Cooperation for the implementation of the Law on the Prevention and Combat of the Abuse of Narcotics - The evidence of drug addicts and abusers’ was signed in February 2010 [15]. With this protocol, state, NGO, and private sectors have an obligation to collect report and share information as well as to provide detoxification, drug treatment, rehabilitation, religion-based rehabilitation and other forms of drug treatment [11].

The results of our study must be viewed in the light of several limitations. First, RDS data questions were read to participants and some answers may have been biased, e.g. drug use. Data on oral health was based on participants’ self–reports and further work should be carried out in collaboration with dentists for an objective assessment of oral health. Although it is helpful to run weighted and unweighted analyses, we did not collect the RDS data that were needed to generate weights. Future investigations should include variables which more precisely describe oral health and problems (e.g. filled tooth index, decayed and missing teeth). Information on dental problems and oral health status were self-perceived as well as those on dental service use and may be subject to recall bias. Sample size was generally small and women represented only a small number of the respondents.

These findings suggest that older participants, part–time employment, unemployment, longer duration of heroin injection and participants who did not have good oral hygiene habits such as frequent tooth brushing and regular dental checkups, had bad oral health. Planning services for IDUs should be based on collaboration between public health professionals who work on HIV prevention among IDUs and dentists which may lead to better programmes and oral health care for this disadvantaged group. Studies on oral health could also involve monitoring the behavior and health of other hidden populations such as commercial sex workers and the homeless. This would help to understand their needs and to direct the development of an adequate social response.