BULGARIA New Development, Trends and In-Depth Information on Selected Issues

2010 NATIONAL REPORT (2009 data) TO THE EMCDDA by the Reitox National Focal Point

BULGARIA New Development, Trends and in-depth information on selected issues

REITOX

Table of content of the report

# Chapters Page

Summary 4

Part A: New Developments and Trends 1. Drug policy: legislation, strategies and economic analysis 7 2. Drug use in the general population and specific targeted-groups 20 3. Prevention 29 4. Problem Drug Use 45 5. Drug-related treatment: treatment demand and treatment availability 48 6. Health correlates and consequences 54 7. Responses to Health Correlates and Consequences 61 8. Social correlates and social reintegration 67 9. Drug-related crime, prevention of drug related crime and prison 73 10. Drug Markets 86

Part B: Selected Issues 11. History, methods and implementation of national treatment guidelines 96

Part C: Bibliography Alphabetic list of all bibliographic references used 99 Alphabetic list of relevant Internet addresses 100

Annexes List of tables and graphs used in the text 102

Summary

In 2009 by Order № РД -09-436/20.08.2009 of the Minister of Health interdepartmental work group was established to prepare a project to amend the Drugs and Precursors Control Act. The amendments have been proposed by the governing body of the Ministry of Health and adopted at a session of the Council of Ministers.

By the end of 2009 26 Regional Councils on Narcotic Substances (RCNS) and 23 Prevention and Information Centers (PIC) have been established. The RCNS and the PIC are funded by the funds from the state budget, through the municipal budgets, as delegated state activity.

There are no new data on the use of drugs in the general population in Bulgaria. The results from the latest representative surveys among the general population can be found in the 2008 and 2009 Annual Reports on the Issues Related to the Use of Drugs in Bulgaria. Besides the international projects 22 surveys were carried out in the 2005-2009 period among students (grades 7 through 13) in 18 cities in the Republic of Bulgaria by applying the NFP methodology. Everywhere the data indicate that marijuana is the most widely used illicit substance. The group of the users of synthetic stimulants can be identified as the second largest group in terms of illicit drugs – we refer mainly to amphetamines and ecstasy-type substances.

In 2009 an increase of the respective share of the activities for the general prevention was observed compared to the European practice, and also to that in Bulgaria compared to the preceding years. This year in our country the trend of reducing the number and the respective share of the activities for the selective prevention holds again, but on the other hand the share of the activities for the indicative and general prevention has increased. It can be said that a trend is noted of reducing the activities of the selective prevention at the expense of the expansion of the activities directed to the general and indicative prevention.

There are no new up-to-date details on evaluations of problem drug use at national level. According to the data provided by the Regional Police Directorates, the total number of individuals (users and dealers) registered with the “Drugs” Department in 2009 was 4632, which is 21 % up from the 2008 level (3823).

The treatment of patients, addicted to narcotic substances includes programmes based on medication-assisted treatment (detoxification and medicinal treatment – Naltrexone, Methadone and Substitol) and psychosocial rehabilitation programmes of the type of "Therapeutic Community" and daycare centers. There is a network of treatment facilities and treatment programmes in place in the country, which ensures passage through the individual stages of treatment. A trend in the development and expansion of the network is the increase in the number of the positions in the programmes, that are partially or fully funded from the state and municipal budgets, as well as the provision of a greater number of programmes for medicine free treatment.

According to the data provided by the National HIV Confirmatory Laboratory, 171 new HIV-positive persons were registered in Bulgaria in 2009. 74 out of them (43.27 %) are injecting drug users.

exchange of needles and syringes, and for doing tests for blood-borne and sexually transmitted infections.

According to data from the District Police Directorates in 2009 in Bulgaria the total number of detainees with drugs was 3159 1, which confirms the trend from 2006 of an increase in the number of arrested persons. In 2009, for drug and precursor crimes (against public health and trafficking/customs smuggling of drugs), the total of 5291 pre-trial proceedings (PTP) were observed compared to 4332 pre-trial proceedings in 2008 and 4609 in 2007.

Despite geopolitical changes in the international routs of heroin, Bulgaria remains an objectively established connection in the trafficking of the drug between Southeastern and Western Europe.1 According to Interpol data, after 1991 this is one of the main drug routes from Afganistan and Turkey crossing the Eastern Balkans (Bulgaria– Romania – Hungary) to Austria, Germany and Netherlands. This rout was loaded mostly in the period 1993– 2001, namely during and right after the wars in Yugoslavia in order hostilities and seizures to be avoided. During this period on the average of 86,9% of Afganistan heroin and morphine was trafficked through the route. The Western Balkan countries (Bosnia and Herzegovina, Croatia, Macedonia, Serbia и Monte Negro, Kosovo) are transit parts of the Balkan heroin road. Especially topical is the route from Afganistan and Turkey through Bulgaria– Macedonia – Kosovo – Albania – Italy.

As a result of the activities of departments in the Ministry of Interior (MI) in combating trafficking and distribution in 2009 were discovered and seized a total of 581 kg, 6900 doses, 30 balls, 301 ampoules, 19.5 kg and 40 l other drugs and precursors. 2 As a result of specialized police operations conducted throughout the country have seized a total of 9266 kg dry mass and 615 kg green mass cannabis, 41 kilograms of marijuana, 623 sticks and 0,323 kg of cannabis seeds. In 2009, customs officials prevented 105 cases of illegal narcotics with a total of 1,242.037 kilograms, 2005 tablets and 4 cactus. Observed number of cases has increased by about 28% over the previous year, and seized quantities are similar.

In 2009 grows number of analyzed objects, containing hemp. During the year the percentaged of tetrahydrocannabinol (THC) in these objects has increased, while in hashish the percentage of THC is not very high, even declines. In heroin samples no significant change either in number or in content of active component. There is a slight increase in objects than in previous years. Further additivites in heroin are the most and paracetamol, but there are piracetam, benzocaine and phenobarbital. Three-year period 2007-2009 samples, containing cocaine begin to rise slightly and there is a tendency to maintain an average level of purity about 20-25 %. Admixtures in cocaine become more varied: paracetam, benzocaine, procaine, caffeine, lidocaine, tetracaine, phenacetin and levamizol.

1 Report on the work of the District Police Directorates along drugs lines for the period 01.01.2009 - 31.12.2009. 1 Source: “Drugs and Terrorism”, Kitan Kitanov, PhD 2 Draft Report of the “Coordination and Information Analysis “ Directorate– MI Implementation of the Action Plan for National Strategy to Combat Drugs in 2009.

Part A: New Developments and Trends

1. Drug policy: legislation, strategies and economic analysis

Within the frames of this section the following main topics will be reviewed: Legal framework; National action plan, strategy, evaluation and coordination; Economic analysis.

Legal framework

Acts, regulations, directives and guidelines in the sphere of drugs (demand and supply)

The amendment of the Act was in relation to the necessity of:

1. Harmonizing the DPCA with the amendment of the Pharmaceuticals Serving Human Medicine Act, in effect since August 12 th 2008 and concerning the legal entities that can be granted authorization for the production, wholesale and retail of pharmaceuticals. Holding an authorization according to the Pharmaceuticals Serving Human Medicine Act in Human Medicine is an obligatory prerequisite for applying for licenses for activities with pharmaceuticals containing narcotic substances under the Drugs and Precursors Control Act.

2. Specifying the establishment of municipal councils on narcotic substances and prevention and information centers in the municipalities, which are regional centers. The ways to fund the municipal councils on narcotic substances and the prevention and information centers have been specified - through the municipal budgets as state- delegated activities.

3. Including the national coordinators on drugs as members of the National Council on Narcotic Substances (NCNS).

4. Specifying the texts related to the control of the activities of treatment and psychosocial rehabilitation of the drug dependent persons. It has been regulated specifically that the specific control on the territory of the country over the treatment of the drug dependent persons is done by the National Center for Addictions, with the help of the drug inspectors at the Regional Health Centers.

5. A new article in the DPCA has been written, pursuant to which at The National Center for Addictions at the Ministry of Health an official data base is established of the individuals enrolled in the programs for the treatment of drug addictions.

6. It has been explicitly written in the act, in Chapter 6 – “International Cooperation” that at the National Center for Addictions at the Ministry of Health A National Focal Point is established as a part of the European network for information in the sphere of drugs and addictions. In fact such a directorate has been established and functions and the tasks of the National Focal Point have been specified in the statute of the structure and activity of the National Center for Addictions.

7. Specifying the regulations concerning the control of the import of cannabis and cannabis seeds not meant for sowing and supervised by the Minister of Agriculture and Foods. It is provided that the Minister of Agriculture and Foods is the administrator of the revenues from the taxes to issue authorizations for activities under Art. 29 and Art. 32a.

8. Specifying the texts from the annexes № 1, 2 and 3 concerning the prohibition to advertise narcotic substances and plants to the public and the pharmaceuticals containing narcotic substances.

9. Regulating the supply and storage of pharmaceuticals containing narcotic substances at special warehouses of the state medical reserve and at the wartime stocks of the Ministry of Interior and the Ministry of Defense, which is to be done after issuing an authorization following a procedure specified by a regulation of the Council of Ministers.

10. Bringing new substances under control pursuant to the annexes to the act: - 9 substances in Annex № 1 , ”Plants and substances of high-degree risk for the public health forbidden for use in the human and veterinary medicine because of their noxious effect and abuse” – 1-benzylpiperazine; 4-bromo-2,5-dimethoxyphenylamine; 2,5- dimethoxy-4-iodophenetilamine (2C-I); 2,5 dimethoxy-4-ethylthiophenetil amine (2C-T-2); 2,5 dimethoxy-4-(n)- propylthiophenetilamine (2 С-T-7); 4- methylthioamphetamine (4- МТА ); para-methoxymetamphetamine (РММА ); 2,4,5- trimethoxyamphetamine (ТМА -2); phenylpiperazine and its halogen derivatives. - 1 substance in Annex № 2, ”Substances of high-degree risk which are administered in the human and veterinary medicine” – codeine-N-oxide. - 5 substances in Annex № 3, “Risk substances, which are administered in the human and veterinary medicine” – 1,4-butandiol; gammabutirolactone; gamma- hydroxibutiric acid; ketamine; chloralhydrate.

In April 2009 The National Assembly adopted a new Penalty Enforcement and Arrest Act (promulgated in the State Gazette issue 25 from April 3 rd 2009, in effect since June 1rd 2010). By further developing the regulation of Art. 41, Para. 6 of the Criminal Code the Act to Amend the PEAA provides regulations to determine the initial and the succeeding regime of serving the “deprivation of freedom” penalty for individuals suffering from alcoholic or narcotic dependence. Besides, it is explicitly shown in the act that the individuals deprived of freedom have to undergo a thorough medical examination after their admission to the admission wards of the prisons which allows for them, in case a dependence has been found, including drug dependence, to be monitored by the doctor- psychiatrist or the inspector-psychologist. 3

Law Enforcement

The effective control of drugs is based on the concept of the “balanced approach”. The beneficial international cooperation, the consolidation of the relations and the improvement of the data coordination, as well as the full value use of the capacity of

3 Report on the implementation of the Action Plan to the National Anti- Drug Strategy over the period 2009 – 2013 г, “Coordination, Information and Analytical Activity” Directorate (CIAAD) – Ministry of Interior (MI), 2010

Europ оl and of the other structures of the EU are one of the basic prerequisites for limiting the production and trafficking of drugs .4

For the implementation of the strategic goals in the sphere of reducing drug supply the following activities have been implemented:

• In 2009 the customs officers prevented 105 cases of illegal trafficking of drugs. • For the storage and destruction of drugs 2,692 correspondences have been instituted for the reception of drugs. • The administrative capacity of the unit for operative analysis at the “Drugs’ Department - Chief Directorate to Combat Organized Criminality (CDCOC), has been increased - 5 new officers have been appointed, the processing of the incoming information and its inclusion into the data base has been ensured. The operative staff participates actively in the operational and reconnaissance projects at the “Initiative for Cooperation in South-East Europe” Center (ICSEE/SEKI) in Bucharest and 5 joint operations were conducted in 2009. • Within the frames of the international cooperation constant exchange of information is done with EUROPOL, INTERPOL and the police services of the other countries. 11 operations under cover have been performed, including by studying the best practices of the member countries of the EU of how to use officers under cover in combating drug trafficking. A specialized section from the staff of the investigating policemen for the investigation of drug-related crime has become autonomous. Regular specialized training of the officers from the Chief Directorate to Combat Organized Criminality is done to acquire and increase qualification in the sphere of combating drug trafficking. • In 2009 17 organized criminal groups connected with drugs were neutralized by CDCOC. • For the storage and destruction of narcotic substances 2,692 correspondences for the reception of drugs have been instituted. 1,892 kg of drugs have been destroyed on the information from 1,936 correpondences.

In 2009 The State Agency for National Security (SANS) provided information to the law guardian bodies and participated in joint operations with the Ministry of Interior (MI), the prosecutor’s office and the National Investigation Service (NIS) as follows:

Information has been provided to the Sofia Municipal Prosecutor’s Office (SMPO) about the functioning of a cross-border channel for transfer of phenylacetic acid from Serbia to Bulgaria;

A joint specialized operation has been carried out by the State Agency for National Security (SANS), MI, the National Investigation Service (NIS) and the Sofia Municipal Prosecutor’s Office on the territory of Sofia, Montana and Vidin, and the members of an organized criminal group for trafficking of and illegal trade with precursors were detained. 60 kg phenylacetic acid, illegal weapons, counterfeit currency and doses of amphetamine were seized. Charges have been pressed against 9 individuals. 4 verdicts of conviction have come into effect;

An organized criminal group for illegal production and trafficking of synthetic drugs from Bulgaria to the Middle East has been detected using the information presented by the SMPO. Within the frames of the operation more than 100, 000 ampoules containing the “Winstrol” anabolic steroid of approximate market cost BGN 1,500, 000 were seized. The activity of the illegal workshop for the production of the ampoules has been

4 Report on the implementation of the Action Plan to the National Anti- Drug Strategy in 2009 – 2013, “Coordination, Information and Analytical Activity” Directorate (CIAAD) – MI, 2010

discontinued. It was located on warehouse premises of a car service in Sofia. 5 Bulgarian citizens have been detained.

Individuals involved with the activity of a transnational organized criminal group (OCG) for the production and trafficking of drugs and precursors and for the preparing of forged credit and debit cards have been identified;

In the month of August 2009 the activity of an organized criminal group acting in the region of the towns of Sofia, Slivnitsa, Bozhurishte, the cross-border check point- Kulata and Ilinden was stopped by employees of the SANS and of the NIS. 5 of the members of the OCG were detained.

Forged credit cards and equipment for their preparation have been seized and so were illegally owned arms, international passports with forged visas for the SAR, chemical formulae for the production of synthetic drugs, etc. ;

At the port of Varna during the customs control of a container coming from Bolivia 1,020 bottles of dissolved substance reacting to cocaine were found. The total quantity of the cocaine detected was 231,54 kg, with a total value (according to the prices of the judicial system) of BGN 61,300, 000.

By virtue of the Committee for Finding Property Acquired through Criminal Activity a decision was made to institute proceedings to find out the property, acquired through criminal activity, of two individuals from the town of Doupnitsa, who are participants in an OCG for drug trafficking.

At the Chief Directorate “Combating Organized Crime” – Ministry of Interior – CDCOC-MI there is an ongoing process of compiling data base for the registration, categorization, and surveillance of the criminal contingent related to drugs

From the reports, submitted to the SANS, on suspicious operations committed by individuals pursuant to Art. 3, Para. 2 and Para. 3 from the Measures Against Money Laundering Act (MAMLA), after an analysis has been done of the suspicious operations, of the systems for money transfer and of the contracts for investment, etc., on the data from 5 of the correspondences there was evidence of laundering money, acquired by trafficking and supply of drugs. Exchange of information about the cases has been done with the foreign financial and intelligence services in Belgium, Norway, the USA, the British Virgin Islands, Turkey, etc.

During the last year a total of 132 letters of inquiry were received by SANS from the financial and intelligence services of foreign countries. In 8 of them (5 from Great Britain, 1 from Serbia, 1 from Belgium and 1 from Macedonia) there was evidence or suspicion of laundering money originating from trafficking or supply of drugs. In a number of the inquiries the point is about investing funds of unclear origin in estates in Bulgaria, as well as in other countries. At the request of the prosecutor’s office and in relation to the needs of the specialized directorates of the SANS additional information using the international exchange has also been collected. For the information exchange the protected network of the International Organization of the Financial and Intelligence Services (Egmont group) has been used, as well as the system of exchange of information between the financial and intelligence services of the countries.

Other restrictive measures undertaken during the year passed are the 5 check – ups done jointly with the bodies for supervision over the activities of the individuals obligated under the Measures Against Money Laundering Act (MAMLA) for whom there is evidence that they have used funds acquired through trafficking of drugs and distribution of drugs.

Cooperation has been provided for the organizing of trainings to prevent money laundering and to counteract drug-related crime. Training seminar has been organized on topic “Fund to confiscate the property acquired through crime related to illegal distribution of narcotic substances, money laundering and investigation of property”. Regular work meetings are held with the prosecutors from the “Money Laundering” Departments of the Supreme Cassation Prosecutor’s Office and from the Sofia Municipal Prosecutor’s Office aimed at optimizing the enterprises directed against committing drug-related crime. Measures have been undertaken to impose punitive sanctions for crime resulting in enrichment of the perpetrators with funds acquired through drug distribution and drug trafficking, by enforcing the regulations of Art. 53 of the Criminal Code for the confiscation of possessions, acquired by criminal activity, to the benefit of the state. In view of the cross-border nature of the drug-related crime, and respectively of the money, acquired through it, close cooperation with INTERPOL, EUROPOL and the officers for contacts with Bulgaria – members of the EU- FIUNE Т, has been established 5.

Measures have been undertaken for imposing punitive sanctions for crimes resulting in the enrichment of the perpetrators with funds acquired through drug distribution and drug trafficking by enforcing the regulations of Art. 53 of the Criminal Code (CC) for confiscating property, acquired through criminal activity to the benefit of the state. In view of the cross-border nature of the drug-related crime and respectively of the money, acquired through it, close cooperation has been established with INTERPOL, EUROPOL, and the officers for contact with Bulgaria 6.

For applying measures on the part of the state, related to limiting the distribution of narcotic substances in the region of educational and children’s establishments and the regions around them, specific measures have been undertaken to prevent the distribution of drugs. In relation to “Juvenile Delinquency” on the territory of the whole country 2,813 specialized police operations have been carried out to counteract the crime related to the distribution of narcotic substances near to and in the school regions. The studying of the good practices of the member countries of the EU continues, and is done within the frames of the twining project “Enhancing the administrative capacity of the police in the sphere of drug - related crime at national and regional level”. Within the frames of the Educational Program for the employees of the “Customs” Agency a total of 16 courses have been conducted, including 3 on “Synthetic Drugs and Precursors”; 3 courses for the employees from the department for combating drug trafficking at Sofia Airport; 10 educational courses for the customs officers – customs dog leaders. Under the program UTTE-2 specialized technical equipment has been received for assembly and disassembly of tyres; 5,760 field drug tests and 4 sets of equipment for nocturnal vision.

A permanent priority of the MI is the enhancement and the maintenance of the professional skills and specialized knowledge in the sphere of combating financial crime. The officers of the CDCOC have participated in work meetings and seminars, educational missions and other forms of education, related to counteracting laundering of money and funding the drug-related crime, as well as incorporating into the economic turnover the funds acquired through sale and distribution of narcotic substances.

National Action Plan, Strategy, Evaluation and Coordination

5 Report on the implementation of the Action Plan to the National Anti- Drug Strategy in 2009 – 2013 “Coordination, Information and Analytical Activities” Directorate– MI, 2010 6 Report on the Implementation of the Action Plan to the National Anti-Drug Strategy 2009 – 2013 Coordination, Information and Analytical Activities” Directorate – MI, 2010

National Action Plan and/or Strategy

On the third regular session of the National Council on narcotic Substances, which took place on October 22 nd 2008, the National Anti- Strategy 2009-2013 and the Action Plan to it were presented and adopted. The National Strategy has the following general contents: INTRODUCTION PART І. ANALYSIS OF THE SITUATION (State and trends; Analysis of the activity in the sphere of drug demand reduction; Analysis in the sphere of drug supply reduction; Legislation) PART ІІ . GLOBAL GOALS AND PRINCIPLES. PART ІІІ . STRATEGIC SPHERE OF ACTION : Drug demand reduction. PART ІV. STRATEGIC SPHERE OF ACTION: Drug supply reduction. PART V. INTERSECTED SPHERE OF ACTION: Public information and scientific and research activity. PART V І. INTERSECTED SPHERE OF ACTIVITY: National coordination and international cooperation. PART V ІІ . INTERSECTED SPHERE OF ACTIVITY : Perfecting the legislation. PART VІІІ . MECHANISM OF IMPLEMENTATION (Coordinating body; Institutions responsible for the implementation at national and local level; Partners for the implementation; Funding the activities and control of the expenditure; Monitoring of the implementation of the National Strategy)

Implementation and evaluation of the National Action Plan and/or strategy

At the sessions of the NCNS reports on the implementation of the Action Plan to the National Anti-Drug Strategy have been adopted for 2003-2008, for 2008 and for the 5-year period of the strategy. The Annual Report of the Republic of Bulgaria for 2008 on the problems related to drug use and drug addictions has been accepted.

By the end of 2009 26 Regional Councils on Narcotic Substances (RCNS) and 23 Prevention and Information Centers (PIC) have been established in the towns of Blagoevgrad, Bourgas, Varna, Veliko Turnovo, Vidin, Vratsa, Gabrovo, Dobrich, Kiustendil, Kurdzhali, Pazardzhik, Pernik, Pleven, Plovdiv, Razgrad, Rousse, Silistra, Sliven, Smolian, Sofia, Haskovo, Shumen, and Jambol.

Reports on the activity of the RCNS and the PIC have been prepared and presented.

The work of the RCNS and PIC can be summarized in the several following trends: - Implementation of the accepted prevention programs and strategies; - Prevention activities among students, parents, teachers and pedagogic counselors; - Conducting competitions, exhibitions, seminars, round tables and presenting the problems of drug use and abuse, jointly with other municipal structures; - Issuing different types of prevention, information and health-educational materials; - Informing the public about the activity of the PIC; - Cooperation with the media to ensure the adequate and competent information about the drug problems.

The efforts of those working at the prevention and information centers are aimed at overcoming the apathy of society in relation to the problem of drug abuse.

Prominence is given to the development and functioning of consultative programs or offices. They should refer the dependent persons for treatment on the territory of the region or on the territory of the country and abroad.

There is good cooperation with the non-government sector, as well as comparatively good coordination among all the municipal structures on undertaking action in combating drugs and addictions.

Last but not least it is worth noting the activity of the PIC in relation to instituting inquiries about the attitudes of the students, parents and teachers and the research to evaluate the distribution and treatment demand, in coordination with the National Center for Addictions.

Pursuant to the regulation of Art. 15a, Para. 2 from the Drugs and Precursors Control Act at the fourth regular session of the National Council on Narcotic Substances for 2009 the report on the activity of the RCNS and of the PIC 2008 was presented and approved.

On November 26 th - 27 th 2009 the Third National Meeting on the problems of prevention, use and abuse of drugs was held. Representatives of the PIC and of the RCNS, the national coordinator for drugs from the Ministry of Health, members of the secretariat of the NCNS and employees from the National Center for Addictions participated in the meeting. Project № BG0011”Listen to the Child – improving the prevention and the access to services of children and adolescents, experimenting with and using narcotic substances”, examples of good practices in the prevention activities in Bulgaria, a Bill to amend the Drugs and Precursors Control Act, (DPCA) were presented during the meeting. A decision was made that RCNS and the PIC should submit their opinions and suggestions about the bill to amend the DPCA to the NCNS for inclusion in the bill.

Other facts for the development of the policy in the sphere of drugs

By the month of July 2010 around 200 Internet sites were reviewed, particularly the forums they contained, with the aim of finding discussions on the topic of drugs and more precisely initiatives of the civil society for the purpose of the development of national policy. Of those reviewed 39 7 sites have discussions on the topic focused. 479 topics 8 were announced and 9,944 opinions 9 were shared.

On reviewing the selected forums the impression was that the topics related to drugs were most often a part of the category “health” and “general topics”, nearly 2/3 of all the topics were related to marijuana, and the remaining ones were related to amphetamines, heroin, hallucinogens, pharmaceuticals, alcohol, etc.

15% of all the topics refer to amendments in the Bulgarian legislation, particularly the Drugs and Precursors Control Act, and are most often titled “For or Against the Legalization”, “For the Legalization?”.

In 2009 a petition entitled “Decriminalization of the marijuana and its use for medical purposes” was planned and prepared. This petition was aimed at voting amendments of the narcotic substances act in the Republic of Bulgaria so that the marijuana could be

7 4 of the sites are entirely related to the topic of drugs, the rest belong to the “lifestyle” category (among them there are sites for science, music, law, school, hobby, etc.) 8 52% of the topics were discussed in 2009 г., 27% started in 2009 and continued through 2010 (reference done by July 2010), 11% started in 2008 and ended in 2009 (reference done by July 2010) and 10% started in 2008. Around 25% of the topics were related to growing marijuana at home (‘indoor’ or ‘outdoor’). Most of the opinions concerned mainly consultations about the problems and the care of the growing and discussions on the equipment necessary for the growing. 20% of the topics were related to the purchase of seeds for the future growing of marijuana (this will be reviewed in Chapter 10) as well as topics related to “material” demand in a definite city. 20% of the topics were related to sharing personal experiences after the use of marijuana mainly. Nearly as many are the topics related to information about the types of drugs and the after- effects of the use. 9 It has to be considered that an author may have several opinions. The number of the opinions given is for 2009 .

moved to the list of enteogens and all the MAJOR marijuana users be allowed to own 1-2 grams for personal use“10 .

On the other hand at the end of 2009 the “Mothers against Drugs” Association presented to the press their requisitions, related to amending some of the Acts. This initiative has been held ever since 2004 and besides presentations to the newspapers letters are written to the National Assembly, and meetings are held with members of the Parliament, but so far there has been no positive response from the state institutions. The “Mothers against Drugs” Association insists on 11 :

1. Proper treatment of drug-dependent persons:

• establishing detoxification wards in every regional town • establishing accessible sites for drug-free treatment • putting the Naltrexon medicine on the positive pharmaceutical list / currently in Bulgaria it is under the trade name Adepend/. It is shown as a good practice by the EU • strict control on the part of the MH and the law guardian bodies over the private practices and avoiding the at random prescribing of opioid pharmaceuticals • improving the conditions at the specialized hospitals for the treatment of drug dependencies- Suhodol, the ward for addictions in Radnevo, еtс.

2. Amending the act with the option “treatment instead of prison” for minor offences, the cause for which has been the drug dependence. Discontinuing the practice of discharging people from the institutions for long treatment and sending them to prison, legalizing their stay there according to their effective sentence, and recognizing it as serving a term after the respective control measures.

3. Applying programs for treatment of drug-dependence at the places of deprivation of liberty.

4. Facilitating the option of compulsory treatment of the drug-dependent individuals in case of extreme forms of aggression and self-aggression, amendment of the Public Health Act.

5. Assistance on the part of the state to the civil organizations, which have as their main object of activity rehabilitation from drug addiction and can prove good practice.

In September 2009 parents of drug dependent individuals from the town of Gabrovo had a meeting with the MP Mrs. Galina Bankovska and they shared with her the problems their children had and the solution of which the state had delayed for so long. With Mrs. Bankovska as their commissioner they submitted an Appeal to the National Assembly in which they had stated the main difficulties they had faced when supporting their children in the fight against the drug dependence. Through the regional media they spoke about the numerous unsolved problems concerning the treatment, rehabilitation and the re- socialization of the drug dependent young people. Since the treatment is not an alternative to the prison, this condemns many young people, who have already initiated treatment, to going to prison, and in most of the cases this puts an end to their efforts to get cured. The lack of a long-term program for assistance and prevention of a recurrence for the people who have undergone treatment for dependence, as well as the lack of a

10 Link of the petition: http://bgpetition.com/dekriminalizaciya/index.html . By May 2010 a user of the forum noted that 144 signatures were collected. 11 Source of information: “Mothers against Drugs” Association.

Day Center for the rehabilitation and re-socialization of the dependent individuals in Gabrovo makes the integration of these young people in the society all the more difficult 12 .

Organization of the coordination

Activities related to the National Drug Council (NDC): At a session of the Dublin group held on June 22 nd 2009 in Brussels a declaration was presented, approved by the NCNS and signed by the chairperson of the of the NCNS for participation of Bulgaria in the Dublin group. The candidature was approved. At a session of the NCNS a decision was made for the national coordinators for drugs of Bulgaria to attend the sessions of the group.

The annual report of Bulgaria for 2008, addressed to the Commission on Narcotic Drugs at the Economic and Social Council of the UN – Vienna (UN ECOSOC), was approved at a session of the NCNS implementing the international contracts for control over drugs.

At a session of the RCNS a questionnaire was approved, sent by the United Nations Office on Drugs and Crime, about “A study of all aspects of the use of cannabis seeds for illicit purposes.”

At a third regular session of the RCNS information was presented and approved about the implementation of resolutions of the UN Commission on Narcotic Drugs – Resolution 51/11 ”Links between illicit drug trafficking and illicit firearms trafficking”, Resolution 52/8 ”Use of pharmaceutical technology to counter drug-facilitated sexual assault”, Resolution 51/18 ”Strengthening international support for states in West Africa in their efforts to combat drug trafficking.”

Economic analysis

Public expenditures

The National Center for Addictions as an independent legal entity at the Ministry of Health, pursuant to the State Budget Act for 2009, received the planned sum of BGN 302, 983.13 From the funds granted, according to the financial report of the NCA, BGN 264, 406 were spent. All the funds spent for wages, for insurance payments, for remuneration of external persons and companies, according to contracts concluded and services done, have been made on grounds of the effective legislation. For the Action Plan to the National Program “National Anti-Drug Strategy” in 2009 the sum of BGN 68, 383.23 was granted, and from it for the activity of the NFP the sum of BGN 8, 873.23 was spent.

Pursuant to the Grant Agreement for gratuitous assistance for action with the European Monitoring Center for Drugs and Drug Addictions for the activities of the NFP BGN 116, 880 14 were spent.

In implementing task 1.6. from the National Anti-Drug Strategy (2009-2013) in 2009 the State Agency for Child Protection (SACP) funded the making of two documentaries

12 On the data from the Annual Report on the prevention activities done by the RCNS and PIC- the town of Gabrovo for 2009 13 Source of information: On the data from the annual financial report of the NCA, prepared by the chief accountant of the NCA- A. Hodonovski 14 Source of information: Annual financial report of the NCA

related to the problems of addictions- “Casting” and “In Order to Live”15 . Work meetings and seminars with the specialists from the system for child protection were organized. They were also used for the dissemination of the “The Known and the Unknown Teenager” manual on drug prevention, meant for social workers. The SACP has funded the introduction and the functioning of an all-European telephone number for children at risk -116 111, and through this Bulgaria became the 14 th country – member of the European Union to implement Decision 2007/698/ ЕО of the European Committee 16 . The line is free for the users and provides accessible way for receiving specialized help at any time of the day or the night. The line has also been used by parents.

At the end of 2009 under the twining project BG2007/IB/JH/12 – „Strengthening the Role of the Prison System” training was done of the employees from the detention places for persons under investigation in Varna, Plovdiv and Sofia for adopting and implementing a short-term program “Harm Reduction from Drug Use” 17 . The strategic purpose set for introducing a 12-step program in all the penitentiaries in the country has not been totally fulfilled because of the impossibility to fund it. In two of the prisons the program has been probated, but after an analysis done its implementation was discontinued because of the impossibility to provide a team to work only after this program. Besides it is not possible for the participants in the program to be accommodated in separate bedrooms for a long time 18 . As a measure to limit the distribution of drugs in the prisons and in the detention places for persons under investigation the purchase and placement of scanners for the luggage has been planned. In 2009 however, such equipment was not provided because of lack of financial resources 19 .

The “Social services for social inclusion” plan of the Ministry of Labour and Social Policy (MLSP) is aimed at applying new and sustainable complex approaches to improve the quality of life of the vulnerable groups, including of the drug dependent individuals and prevention of the social exclusion and overcoming its aftermaths 20 . The plan includes three components, one of which is oriented to the development of innovative forms of social services, which have not been regulated by the Implementing Regulation of the Social Assistance Act. Within the frames of this component of the plan a set of social services can be funded so that the dependences could be overcome. The funds allocated for the whole plan amount to a total of BGN 23, 015, 000 and for them all the social service suppliers can apply. The sum of the non-repayable aid can vary from BGN 80, 000 to 250, 000. Employment of people suffering from different type of dependencies is supported by two plans for providing non-repayable financial aid according to the Development of the Human Resources Operative Program 21 . One of the plans „Social entrepreneurship – awareness and support of social enterprises (Pilot phase) with a budget of BGN 15, 680, 000 is aimed at assisting the development of the social entrepreneurship as an option to improve the quality of life of the people from groups at risk and overcoming their

15 Source of information: “Coordination, Information and Analytical a Activities ” Directorate , MI (draft annual report of the NADS) 16 Source of information : “Coordination, Information and Analytical Activities” Directorate , MI (draft annual report of the NADS) 17 Source of information: “Coordination and Information and Analytical Activity” Directorate, MI (draft of the annual report of the NADS) 18 Source of information: “Coordination and Information and Analytical Activity” Directorate, MI (draft of the annual report of the NADS) 19 Source of information: “Coordination and Information and Analytical Activity” Directorate, MI (draft of the annual report of the NADS) 20 Source of information: Ministry of Labour and Social Policy (MLSP), “European funds, international programs and projects” Directorate 21 Source of information: MLSP, “European funds, international programs and projects” Directorate

social isolation. The plan is implemented through a procedure to select projects with eligible beneficiaries–social services suppliers. As a result of its implementation presumably a minimum of 40 models of social enterprises will be established or fully developed, and on the average in them protected jobs for 5 individuals from the vulnerable groups, who are not able to participate in real labour activity, will be ensured. Another option to secure employment for the individuals who have drug problems is a supplement to the “New Opportunities” plan with a budget of BGN 30 million, in accordance to which the municipalities can get up to BGN 300, 000 for the establishment of new social enterprises- social laundries, social dining rooms, enterprises for planting and urbanization, as well as ones providing the technical assistance for the activity of the municipal administrations. Presumably, according to the scheme permanent employment will be secured for at least 800 people from the most vulnerable groups, including for people suffering from different types of dependencies.

The commitments of the Ministry of the Physical Education and Sports for the implementation of the Action Plan of the NADS are related to the strategic task 1 „Improving the options to present to the children and young people attractive ways to spend their leisure time”. These commitments are implemented through the “Sports for the children in their leisure time” program. The target of the program are the children from all over the country who do not practice sport regularly, including the disadvantaged children. In 2009 under the Program 211 projects were implemented, which encompassed approximately 21, 500 children, including 1, 970 disadvantaged children. The greatest number of projects were implemented in Sofia, Veliko Turnovo, Varna, Vratsa, Jambol and Haskovo. The partners of the MPES for these projects are the municipal administrations, the regional inspectorates on education, the school boards, the sports organizations and the mass media. The funds for the implementation of the Program in 2009 were from the budget of the MPES and amounted to BGN 904, 120. 22

The total sum from the budget, allocated to the activities of the RCNS Plovdiv for 2009 was BGN 27, 000. 23 From it for the education of children leaders in 3 modules and in holding 2 seminars BGN 10, 000 were allocated from the budget, for the issuing of manuals and information materials – BGN 14, 500 and for improving the qualification of the members of the MDC and PIC –respectively BGN 2, 500.

In 2009 the funds from the municipal budget used by the RCNS Bourgas for prevention activities related to drugs amounted to BGN 11, 500 24 Of them BGN 1, 500 were for combating and prevention of tobacco smoking, BGN 6, 000 – for organizing and holding enterprises in connection with June 26 th – The World Day to combat the use and illegal distribution of drugs. Also, BGN 4, 000 from the budget were used for the exchange of good practices. For the training of students from 3 primary schools in prevention of risky behaviour related to the use of narcotic substances BGN 30, 000 were spent, provided through a project won by the NGO and by Bourgas Municipality as a partner.

The financial expenditure for activities related to the prevention and to combating drugs of the RCNS Gabrovo for 2009, provided from the Municipal Budget, amounted to BGN 10, 240. 25 They included co-funding amounting to BGN 4, 200 of the “Law in Action” Project of the “Equal Chance 2008” Association implemented in partnership with the association and volunteers from the Youth Council on Drugs – Gabrovo. The project was funded by the “Youth in Action” program of the European Committee and its total cost is EURO 7, 600.

22 Source of information: Ministry of Physical Education and Sports 23 Source of information: Regional Council on Narcotic Substances (RCNS) Plovdiv – annual report 24 Source of information: RCNS Bourgas – annual report 25 Source of information: RCNS Gabrovo – annual report

The budget funds used by the RCNS and by the PIC the town of Pernik and for prevention and information activities in 2009 amounted to BGN 27, 190. 26

The funds from the republican budget, used by the RCNS Silistra for prevention and information activities in 2009 amounted to BGN 1, 955.

In 2009 the budget funds used by the PIC Shumen for the organization of the prevention and information activities amounted to BGN 570.27 In 2009 the RCNS Shumen received

funding from the republican budget as funds for the implementation of the Action Plan of the NADS amounting to BGN 1, 700. 28

The funds from the budget of the RCNS Vidin, used for the activities related to prevention and combating drugs in 2009, amounted to BGN 1, 940. 29

From the budget of the Regional Council on Narcotic Substances in Vratsa in 2009 BGN 10, 000 were used for organizing and presenting a concert “No to the Drug” with the participation of BTR and John Lotan on the initiative “The July from the Balkan to the sea”. The rest of the funds for the concert were provided through organizing a charity cocktail and other donors. 30

In relation to limiting the budget expenditures of the Ministry of Health in 2009, including for the national programs and the delay of their funding, not all the planned activities for 2009 of the Action Plan and the National Anti-Drug Strategy, a commitment of the Ministry of Health, were implemented 31 .

In 2009 “The Law in Action” Project of the “Equal Chance 2008” Association was implemented and this was done in partnership with the RCNS - Gabrovo and with the participation of volunteers from the Youth Council on Drugs – Gabrovo. The project was funded after the “The Youth in Action” Program of the EC and its total cost was EURO 7, 600 32 .

In partnership with the RCNS Gabrovo in 2009 the “INdependece” Project of the “Youth Information Network” NGO was implemented. The project was funded by the “Workshop for civil initiatives” Foundation and its total cost was BGN 6, 500. 33

The RCNS Silistra has funded part of its prevention and information activities through funding projects. The total sum for 2009, provided through projects, amounted to BGN 1, 640. 34

Budget

26 Source of information: RCNS Pernik– annual report 27 Source of information: RCNS Shumen– annual report 28 Source of information: RCNS Shumen – annual report 29 Source of information: RCNS Vidin – annual report 30 Source of information: report 5 / 21.04.2009 of the session of the RDC Vratsa 31 Source of information “Coordination, Information and Analytical Activities” Directorate, MI (draft annual report for the NADS) 32 Source of information: RCNS Gabrovo – annual report 33 Source of information: RCNS Gabrovo – annual report 34 Source of information: RCNS Silistra – annual report

The RCNS and the PIC are funded by the funds from the state budget, through the municipal budgets, as delegated state activity. The funds provided for 2009 are payments for wages for 27 permanently appointed chair persons and for 27 for secretaries of the RCNS and 65 permanently appointed employees for the PIC teams, as well means of livelihood.

Result-oriented funds are granted for prevention activities after the National Program to implement the National Anti-Drug Strategy.

In 2009 because of reducing the funds for the National Program to implement the Action Plan of the National Anti-Drug Strategy no funds were granted for the funding of the prevention activities of the PIC.

The funds granted from the state budget as well as the funds for the prevention activities after the National Program to implement the Action Plan of the National Anti-Drug Strategy are absolutely inadequate for the implementation of prevention activities and more effective work of the PIC.

Social cost

There are no current data about the social cost related to the drug use.

2. Drug use in the general population and specific targeted groups

The following major topics will be considered in this section: Drug use among the general population; Drug use among students and youths; Drug use among individual target populations.

The discussion of the first two major topics focuses on the prevalence among the general population and among schoolchildren. Epidemiological studies conducted at national and local levels have been used as sources of information . The third topic covers up-to-date survey data on the use of narcotic substances among the representatives of specific population groups: persons deprived of liberty and children placed with institutions for children deprived of parental care .

Drug use among the general population

There are no new data on the use of drugs in the general population in Bulgaria. The results from the latest representative surveys among the general population described below can be found in the 2008 and 2009 Annual Reports on the Issues Related to the Use of Drugs in Bulgaria.

With the methodological and financial assistance of the National Focal Point on Drugs and Drug Addictions and in compliance with the EMCDDA standards the local representative surveys on the use of psychoactive substances among the general population (aged 15- 64), launched at the end of 2007 in five district centres (Sofia, Pleven, Blagoevgrad, Sliven, Shumen), were completed in the spring of 2008. The surveys were carried out by MBMD and SOVA HARRIS sociological agencies in cooperation with NFP. In general and methodological terms they were a part of a national survey covering cities of varying size, geographic location and type. A total of 6 027 persons in the said age group were covered 35 .

A year later, in December 2008, a national representative sociological survey on the use of psychoactive substances among the general population in the Republic of Bulgaria was launched by the MBMD sociological agency in cooperation with NFP. It also targeted the population in the 15-64 age bracket and the sample was generated by random selection. The processing of the data was completed at the beginning of 2009. A total of 5 139 persons in the said age bracket were covered 36 .

In accordance with the European practice and the “Drug use among the general population” key indicator, the surveys sought to assess the use of drugs, alcohol, cigarettes and medicines in three time ranges and, respectively, by means of three indicators: life time prevalence, last 12 months prevalence, last 30 days prevalence.

35 See Standard Table 1 to the 2008 Annual report on the issues related to the use of drugs in Bulgaria 36 See Standard Table 1 to the 2009 Annual report on the issues related to the use of drugs in Bulgaria

Drug use among schoolchildren and youths

Bulgaria participates in two major projects associated with school population surveys: ECAD and ESPAD.

Under the European Cities against Drugs (ECAD) project, a school survey is conducted once in every 4 years under the heading: “Survey on the life and living conditions of young people in Europe”. It is part of the “Youth in Europe” international programme and involves the cities of Vilnius, Kaunas and Klaipeda (Lithuania), Oslo (Norway), Reykjavik (Iceland), Riga (Latvia), St. Petersburg (Russia), Sofia (Bulgaria) and Helsinki (Finland). The survey is carried out by the Prevention and Information Centre on Drug Addictions, Sofia, with the assistance of the National Focal Point on Drugs and Drug Addictions and partners from different Sofia city municipalities. The latest such survey was performed in the period 8-19 November 2006 and it covered 5181 secondary school students (grades 9-13) from 262 classes in 99 schools.

The European School Survey Project on Alcohol and Other Drugs (ESPAD) is one of the most comprehensive school surveys worldwide and it has been carried out 4 times so far. In 1995 for the first time 26 European countries collected data on the use of alcohol, cigarettes and narcotic substances via school surveys conducted simultaneously by applying standardized methodology and a common questionnaire. The second data collection exercise took place in 1999 with the participation of 31 countries, and the third one was carried out in 2003 with 35 participating countries.

The latest, fourth survey, which was conducted in 2007, covered over 100 000 students from 35 states: Austria, Armenia, Belgium (Flanders), Bulgaria, Great Britain, Germany (7 laender), Greece, Denmark, Estonia, Ireland, Iceland, Italy, Cyprus, Latvia, Lithuania, Malta, Monaco, the Netherlands, Norway, the Isle of Man, Poland, Portugal, Slovakia, the Czech Republic, Romania, Russia, Slovenia, Ukraine, Hungary, the Faroe Islands, Finland, France, Croatia, Switzerland and Sweden.

The main purpose of these surveys is to collect comparable data on the use of alcohol, tobacco and drugs among 15-16 year-old European students in order to monitor trends within as well as between countries.

For Bulgaria, the data collection in 2007 was financed by the National Focal Point for Drugs and Drug Addiction with funding from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), the responsible institutions being the National Center of Public Health Protection and the National Center for Addictions.

The respondents were 5253 students (2884 boys and 2409 girls), grades 9 and 10 in 271 classes .

In addition to supporting Bulgaria's participation in the two major school projects (ECAD and ESPAD), the National Focal Point for Drugs and Drug Addiction has developed a methodology for student surveys at local level. They are aimed at examining certain aspects of the health behavior, assessment and attitudes on addiction issues.

Besides the international projects referred to above, 22 surveys were carried out in the 2005-2009 period among students (grades 7 through 13) in 18 cities in the Republic of Bulgaria by applying the NFP methodology.

Table 2.1

SURVEYS IN ACCORDANCE WITH THE NFP METHODOLOGY CONDUCTED AMONG STUDENTS IN BULGARIA (2005-2009)

Year Cities

2005 Vidin, Kardjali, Kyustendil, Pazardzhik, Razgrad, Dobrich 2006 Gabrovo, Varna, Haskovo 2007 Pleven, Targovishte, Shumen, Silistra, Montana, Vidin 2008 Pernik, Lovech, Plovdiv, Sofia, Kyustendil 2009 Panagyurishte Kardjali

If we look at the surveys in 8 regional cities – Pleven (1397 surveyed students in 2007), Targovishte (1147 students, 2007), Shumen (1496 students, 2007), Pernik (1231 students, 2008), Lovech (1018 students, 2008), Plovdiv (1631 students, 2008), Kyustendil (1095 students, 2008) and Kardjali (1576 students, 2009), we can outline several trends in drug use by students and in their attitude towards this issue.

Everywhere the data indicate that marijuana is the most widely used illicit substance. Most often it has been used at least once in their lifetime by 18 to 22 % of the respondent students in the 8 cities. The only exception is Pleven, where the prevalence is 13.7 % (see Figure 2.1) . The last 30 days prevalence (use during the 30 days prior to the completion of the questionnaire) of marijuana among the students is at the level of 4.0-10.5 %, at that marijuana has been used more than once by 2.0 to 5.4 % of the respondents.

The group of the users of synthetic stimulants can be identified as the second largest group in terms of illicit drugs – we refer mainly to amphetamines and ecstasy-type substances. Those that have used amphetamines at least once in their lifetime are within the range of 4-12 %, the highest level being in Kyustendil (11.6 %). The level of ecstasy use is slightly lower. It ranges between 4 and 7 %, the highest one being in Kardjali (7.1 %) and Kyustendil (7.0 %). The last 30 days prevalence for this group is 2-5 %, while between 0.7 and 3.2 % of the students have used synthetic stimulants more than once.

Cocaine use is growing in popularity. Across the 8 cities it ranges between 2 and 9 %, at that the lowest level is the one in Pleven (2.2 %); the highest one is in Kardjali – 8.6 %. The last 30 days prevalence of cocaine is 1.3-2.8 %, while between 0.5 and 2.0 % of the respondents have used this substance more than once.

On the other hand, the students in Pleven rank second (among the 8 district centres) in heroin use (3.5 %). A higher level has been registered only in Kardjali (4.1%). The last 30 days prevalence of heroin is at the level of 1-3 %, while between 0.4 and 3.2 % of the students have used it more than once.

Other drugs that students admit they have ever used in their lifetime are LSD (with prevalence of 1.6% to 4.0%), anabolic steroids (2.0-4.2%), morphine, codeine and other opiates (1.4-3.9%), pico (0.6-3.5%). Inhalation of adhesives, bronze-powder, etc. refers to 2.0-6.3 % respondent students.

Figure 2.1 LIFE TIME PREVALENCE OF NARCOTIC SUBSTANCES AMONG STUDENTS

8,3% 18,1% 7,1% Kardjali 8,2% 8,6% 4,1%

8,2% 19,2% 7,0% Kyustendil 11,6% 4,9% 2,1%

7,8% 19,2% 4,6% Plovdiv 6,5% 3,5% 2,0%

7,2% 18,6% Hashish Lovech 5,8% 8,9% Marijuana 5,3% 3,0% Ecstasy 4,8% Amphetamines 21,7% 5,2% Cocaine Pernik 8,5% 4,3% Heroin 1,0%

6,9% 17,9% 5,8% Shumen 4,3% 2,7% 2,8%

7,2% 20,1% 4,6% Targovishte 5,5% 2,8% 1,7%

4,0% 13,7% 3,6% Pleven 3,9% 2,2% 3,5%

0% 5% 10% 15% 20% 25%

Source: National Focal Point for Drugs and Drug Addictions

The opinion of the students is that at least one fifth of their classmates have tried a drug in their life time. Parallel with that only 5-10 % believe that someone from their circle of friends has done so.

Some 1/3 of the students have been offered a drug, while 1-4 % have been even forces to use it. Such cases are most prevalent in Shumen (3.7 %) and in Lovech (3.3 %).

An average of one tenth of the respondents have attended a party involving drugs use. This is mostly valid for Kyustendil (14.1 %) and Pernik (13.7 %).

7 to 11 % of the students in the 8 district cities are inclined to accept a proposal by a friend to try a drug. About 1/5 of the respondents are not sure whether they would do so.

On average, about two thirds of the students have never used drugs. This is most pronounced in Pleven (74.9 %), and least so in Shumen (60.7 %), Kyustendil (61.6 %) and Targovishte (61,9 %)

The reason for the first-time drug use as stated by the students across the 8 districts is mostly “for pleasure” (11.0-17.9 %), “out of curiosity” (12.7-17.5 %), as well as “out of boredom” (3.1-5.0 %) (see Figure 2.2)

Figure 2.2

REASONS FOR FIRST-TIME DRUG USE AMONG STUDENTS (in %)

Kardjali 11,0% 13,8% 4,3%

Kyustendil 17,9% 15,4% 4,5%

Plovdiv 13,6% 17,0% 3,8%

Lovech 14,7% 15,1% 5,0%

Pernik 14,6% 17,5% 4,4%

Shumen 13,0% 12,7% 3,1%

Targovishte 14,1% 15,4% 5,0%

Pleven 13,6% 14,7% 3,1%

Pleasure Curiosity Boredom

Source: National Focal Point for Drugs and Drug Addictions

When they have to pinpoint why their coevals use drugs, students once again state as leading reasons “for pleasure” and “out of curiosity”– an average of about 1/2 of them think so. However, they also add to these: “in order to be accepted by the others (the group, the party)”, “in order to escape from reality”, “in order to suppress their own communication problems”, “in order to relieve psychological stress” – an average of approximately 1/3 of the respondents give these reasons.

The students estimate as more or less equal the health risk of regular smoking of cigarettes and of marijuana - about two thirds of them qualify it as high. At the same time regular heroin use is identified as more risky than regular use of ecstasy. On average 4/5 of the students estimate that regular heroin use involves high risk, while the assessment of a high risk associated with regular use of ecstasy is shared by three quarters of them.

Drug use is accepted without reservations by 2.3% to 6.5% of the respondents (see Figure 2.3) . The students from Lovech are most liberal minded on this matter – 6.5 % accept drug use without reservations, while 5.8 % are inclined to accept it. Parallel with that 60.5 % of them definitely do not accept it – this is above the average level for the students from the other district cities that have responded in the same way.

Figure 2.3 RELATIVE SHARE OF THE STUDENTS ACCEPTING DRUG USE WITHOUT RESERVATIONS

(in %)

Kardjali 3,0%

Kyustendil 3,6%

Plovdiv 2,6%

Lovech 6,5%

Pernik 2,3%

Shumen 3,1%

Targovishte 2,6%

Pleven 2,6%

Source: National Focal Point for Drugs and Drug Addictions

When asked whether the use of drugs is a problem for Bulgaria, between 70 and 80 % of the respondents gave an affirmative answer (see Figure 2.4) .

Figure 2.4 IS DRUG USE A PROBLEM FOR THE COUNTRY, CITY, SCHOOL (in %)

59,1% Kardjali 65,2% 74,2%

47,9% Kyustendil 64,2% 76,7%

49,7% Plovdiv 64,9% 76,3%

50,2% Lovech 57,4% 72,6%

49,2 % Pernik 76,1% 79,4% 55,3% Shumen 54,9% 70,1%

51,4% Targovishte 57,9% 70,5%

57,0% Pleven 74,5% 80,5%

Country City School

Source: National Focal Point for Drugs and Drug Addictions

The significance of the problem for the students’ city of residence ranks second. This assessment is most prevalent among the students in Pleven – 74.5 % of them believe that drug use is an issue for their city. Only the students from Shumen come up with the opinion that drug use is an issue for their school rather than for their city.

Drug use among specific target groups / settings at national and local level

Among persons deprived of liberty

According to data provided by the “Execution of Penalties” Directorate General (EPDG) of the Bulgarian Ministry of Justice, in recent years the prisons system has registered an increase in the number of incoming persons deprived of liberty, who are addicted to drugs. This tendency poses serious challenges to the EPDG leadership and respectively to the penitentiary managements. The number of the 2009 drug users and drug abusers recorded at prisons and detention places is 1038. Naturally, these figures are highly dynamic and dependent on the incoming and outgoing of persons. Traditionally, all newcomers have had access to the procedures of health status assessment, needs assessment, assessment of the risk of relapse and of the risk of harm, and involvement in group work for adaptation purposes.37

Among children placed with institutions for children deprived of parental care

In November 2009 the National Focal Point, jointly with the Regional Inspectorate for Public Health Protection and Control, Sofia District (RIPHRC, Sofia District) conducted a survey among children placed with institutions for children deprived of parental care (ICDPC). The topic of the survey was “Attitudes towards psychoactive substance use and risky sexual behavior” at the institutions in the villages of Razliv and Doganovo and at the town of Dolna Banya. A total of 70 children aged 10 to 20 took part in it, slightly over half of them being boys and the rest of the respondents being girls. A bit over half of all respondents are 10 to 15 year old, while the remaining part are in the 16 to 20 age group, a quarter of the whole number being 17 year-olds.

Social milieu, awareness of the respondents and reasons for drug use

Before their placement with an institution nearly half of all children lived with one of their parents, and again almost half of them all state that during the past year they have lived with more than four persons in one home. Over half of the interviewed children say that they feel lonely. A quarter of the total number share that they generally come into conflict with children from the institution and nearly as many state that they do not come into conflict with anybody, it is far less common to have children in conflict with parents or with other coevals. As regards discussions on the topic of drug use, most of the respondents hold such discussions with teachers and pedagogical counselors in schools, as well as with educators at the institutions, and nearly half of all children share that they have never discussed with their parents the topic of drugs and in particular that of drug users. Half of the children report relatively high school results, while а quarter of them state that they do not cope particularly well with the educational material. Almost all of them agree that the school is the place where discussions should be held on matters related to tobacco smoking, safe sex, alcohol and drug use, as well as on the issues of violence in their lives. Half of all respondents say that their friends would prevent possible drug use on their part, yet, on the other hand, one third of all respondents reply that their friends would not be interested in such action.

37 Source of information: “Execution of Penalties” Directorate General, Ministry of Justice

As regards awareness of the different kinds of drugs, marijuana is the most recognized narcotic substance, followed by heroin, cocaine and ecstasy, also the largest number of children report that they have only heard about those drugs. The information of the impact and consequences of drug use is most frequently obtained from films or teachers and pedagogical counselors, and the interesting point here is that almost one third of them all state that they are neither aware of nor interested in these matters. Curiosity is the reported personal reason for first-time use of some illicit narcotic substance, while pleasure and acceptance by a party is the reported reason why coevals use a particular drug.

Use of psychoactive substances

Medicines

There are reports of individual cases of use of a psychoactive medicine without a prescription.

Cigarettes

Half of the respondents state that they have never smoked cigarettes, while a quarter of all respondents report cigarette use on the last day. The first-time use occurred at the age of 17 at the latest, and a third of all respondents state that they have smoked on a daily basis or nearly daily basis in the last year.

Alcohol

Slightly over a third of the children report that they have never drunk alcohol and a quarter of them all have drunk alcohol in the last month. In general, the first sip of alcohol was taken at the age of 15 or 16. Half of those that report use in the last 30 days have had up to one drink a day, while the remaining half – 2 to 5 or more drinks per day. Half of the respondents have been drunk at least once, and for over half of them there has been a repeat case. The most popular alcoholic beverage is beer, followed by hard liquor and wine, but beer remains twice as preferred as the other types of alcoholic beverages. A small proportion of the children have had problems related to the use of alcohol and these have been mostly problems with the staff or with peers in the institution.

Illicit drugs

A very small proportion of the respondents say that they have used some kind of a drug in their life time and that the use occurred last year as a one-off case. The drugs used were marijuana, amphetamines, heroin, cocaine, pico and glue.

Risk factors and drug-use attitudes

Respondents’ answers prompt that a part of the risk factors, such as drug supply, are reduced to a minimum, because almost all reply that they have not received such a proposal, and almost none of them has attended a party involving the use of illegal substances. More than half of all children state that they are reluctant to take a medicine on the basis of their own decision in order to achieve a temporary effect, while one third of the total number cannot judge whether they would do such a thing.

Attitudes and judgments on the use of psychoactive substances

A quarter of the respondents believe that all should be punished for possession of narcotics of small quantities for one-off use even if the person is an addict.

Two thirds of the respondents think that drug use is a problem for our country, half of them state that it is an issue for the city, and just as many believe that it is a problem for the school. Strict laws applicable to drug manufacturers and drug dealers, as well as tough laws on drug use are the most preferred measures to tackle drug addiction in our country. The most common answers are that there is high health risk for people, who smoke cigarettes of marijuana, drink alcohol or use heroin or ecstasy. Nearly one third emphatically do not accept smoking, a slightly greater proportion definitely do not accept alcohol drinking while half of them explicitly do not accept drug use.

3. Prevention

In the present chapter the implemented prevention activities at national and local level for 2009 will be presented, related to the use and abuse of psychoactive substances. The activities implemented include: o General prevention: at school, within the family, and in the municipality / community; o Selective prevention: in groups at risk, families at risk and places for recreation; o Prevention by indication (indicative prevention); o Media campaigns.

Introduction to the structure of prevention activities

For 2009 the implemented preventive and coordinated activities at national level were done mainly in the sphere of the general prevention. The target group of the preventive activities reported were mainly the children and youths, as well as the general population. Unlike the preceding 2008 38 the family/parents were among the main target groups, and for 2009 for this group the lowest activity was reported. The most preferred approach for the implementation of the prevention activities this year again has been oriented at integration to the community, training of professionals, constructing a network and self- help. In 2009 the preventions related to preventive activities were mainly organizing seminars, workshops and training with professionals, as well as writing and disseminating fliers, folders, posters, etc., and creating and maintaining websites.

During the Third National Meeting on the problems of prevention and use and abuse of narcotic substances in November 2009 the National Focal Point on Drugs and Drug Addictions carried out for a second time a probing survey about the nature and scope of the prevention activities at local level. 39

The results of the questionnaires completed show that the general prevention is the dominating one. The target groups of the projects implemented were mainly children/youths and adults. The dominating type of approach of the projects implemented was integration with the community. So far we can say that the situation at local level mirrors the prevention implemented at national level. It is interesting to study, however, whether what happens in reality corresponds to the wishes of the experts who have taken part in the completion of the questionnaires. A comparison will be made of the activities implemented and the activities wished for according to target group and type of approach.

38 For further information see the Annual Report on the problems related to drugs and drug addictions in Bulgaria 2009, Chapter 3 39 The representatives of the Regional Councils on Narcotic Substances (RCNS) and of the Prevention and Information Centers (PIC), plus a representative of a municipality and one representative of the NGO sector from 12 district towns in the country took part in the completion of the questionnaires handed out. Nearly half of the people who responded to the questions are heads of the institution they represent, and the rest are experts there.

Figure 3-1

DISTRIBUTION OF THE WISHED FOR AND IMPLEMENTED PREVENTIVE ACTIVITIES ACCORDING TO THE TARGET GROUP

wished for implemented implemented wished for 33% 6% 7% 24%

implemented 31% implemented wished for wished for 56% 38% 5%

Total population Children/youth Adults Family/parents

Source: National Focal Point on Drugs and Drug Addictions

The children/youths are the most wished for and realized target group, at the expense of the family and the parents, where the wished for projects are several times those of the implemented with this target group. On the other hand, however, the projects implemented with a target group of the adults are 1/3 of all the projects, but they are the most unwanted target group. Figure 3-2

DistributionРазпределение of the approach на реализираниия implemented и желанand wished подход for на of the превантивнитеpreventive activities дейности (%) (%)

Wishedжелан for 3 4 25 64 14 20 6 14 31

Implementedреализиран 8 8 8 52 12 12

0 20 40 60 80 100 120

Насочени към закононарушители Етнически ориентирани интервенции Семейство / ранно детство Полово ориентирани интервенции Телефонни линии за помощ Медийни кампании Въздействие чрез връстници Приобщаване на общността Обучение на професионалисти Изграждане на мрежа Самопомощ

Source: National Focal Point on Drugs and Drug Addictions

Oriented to offenders; Family/Early childhood; Telephone lines for help; Influence by peers; Training of professionals; Self-help; Ethnically oriented interventions; Gender- oriented interventions; Media campaigns; Integration with the community; building up network) In the Figure 3-2 it is seen that the approaches wished for are more than the implemented in reality. Only the training of professionals is the approach equally wished for and at the same time implemented in reality. The integration with the community is the predominating approach applied (52%), but in fact it is one of the most unwanted approaches. ‘Family/Early childhood (25%) alongside with ‘influence by peers (20%) are the most wished for preventive approaches, followed by ‘media campaigns’ (14%) and ‘training of professionals’ (14%). Of all the 16 types of interventions provided, related to preventive activities, the participants in the questionnaires had to choose 5 as preferred (see Figure 3-3).

Figure 3-3

Разпределение на най -желаните интервенции свързани с превантивни дейности

Създаване и поддържане на Обучения тип „ интернет Деца обучават сайтове ; 14% деца ”; 27%

Прожектиране на филми ; 16%

Обучения Организиране на насочени към спортни превенция на мероприятия ; 18% употреба на наркотици ; 25%

Source: National Focal Point on Drugs and Drug Addictions

Trainings of the type “Children train children” (27%) and trainings oriented to the prevention of drug use (25%) are the leaders among the wished for interventions, followed by the organizing of sports events (18%), showing films (16%) and creating and maintaining websites (14%). In conclusion 40 we can say that in 2009 the preventive activities in the sphere of drug addiction were implemented in the scope of the general prevention, mostly among children and youths, and the most widely used approach was through integration with the community, and the interventions most wished for, related to preventive activities, are trainings of the type “Children train children”.

On the data of the RCNS and PIC 41 , the total number of the activities for the different types of prevention for 2009 was 235, almost the same as in the period 2007, and shows an increase compared to the preceding 2008. In the year gone by -2009- the greatest number of initiatives were again implemented in the sphere of the general prevention –

40 Conclusion on grounds of the information from the questionnaires completed by the participants in the Third National Meeting on the problems of prevention of the use and abuse of narcotic substances. 41 City reports of the RCNS and PIC for 2007 – 22 cities, 2008 -24 cities and 2009 -20 cities.

206 (88% of the total number) one point more than in the preceding 2008 and unlike 2007 when these initiatives numbered 181 (76 % of the total number).(see Table 3-1).

Table 3-1

NUMBER OF ACTIVITIES ACCORDING TO TYPE OF PREVENTION FOR THE PERIOD 2007-2009

2007 2008 2009 Total number of the preventive activities 238 200 235 General prevention 181 175 206 Selective prevention 44 12 11 Prevention according to indications 13 13 18

Source: City reports of the RCNS and PIC for 2007, 2008, and 2009

Figure 3-4 ALLOCATION BY TYPE OF PREVENTIVE ACTIVITY

БГ 09 88% 4% 8%

БГ 08 87% 6% 7%

БГ 07 76% 18% 6%

ЕС 73% 23% 4%

0 20 40 60 80 100 120

обща селективна индикативна

The total number of the types of preventive interventions implemented in 2009 was 434 unlike the preceding 2008 when their number had reached 278 . The most widely spread interventions related to preventive activities are organizing seminars, workshops and training with professionals, trainings oriented to prevention of drug use. Like in the previous year the theatrical performances and other cultural events represent the third most important choice of a type of preventive activities. Integration of the community was the most widely applied type of approach in 2009. Also the training of professionals was among the approaches applied. Most often the target group of the preventive projects in the year passed was the general population, while the family and the parents were the object of the fewest preventive projects (see Table 3-2).

Table 3-2

Types of preventive interventions 2007 2008 2009 Showing films 13 19 35 Video-training 5 3 6 Creating and maintaining websites 6 6 17

Making and distribution of fliers, folders, posters, etc. 49 40 36

Printing and distribution of booklets 6 7 11 Organizing sports events 9 8 25

Trainings oriented to HIV and AIDS prevention 3 6 20

Trainings oriented to prevention of drug use 33 30 64

Training of leaders 3 11 6 Trainings of the type “Children train children” 14 36 12 Training for parents and teachers 26 18 24 Organizing seminars, workshops and training with 23 21 77 professionals Activities by the media addressed to the community 27 9 27 Discussion clubs 20 15 14

Theatrical performances and other cultural events 20 35 38

Competitions for best picture, best story, etc. 18 14 22 TOTAL: 275 278 434

Source: City reports of the RCNS and PIC

3.1. General prevention

3.1.1. At school

At national level

At national level the activities directed to prevention of addictions at school are mainly implemented by the Ministry of Education, Youth and Science (MEYS).42 The following activities have been implemented: 1) School programs for prevention of the use and abuse of narcotic substances, based on the “skills for life” approach. 293 programs have been implemented directed at preventing the use and abuse of narcotic substances, 24 of them oriented to preventing the use of alcohol and cigarettes. 400 schools in the country were included and 66, 295 students. 2) School programs for the prevention of use and abuse of narcotic substances, based on the “peers educate peers” approach. 190 programs have been implemented (90 of them for alcohol and cigarettes) at nearly 300 of the schools in the country and 28, 110 students have been included. 3) Campaigns carried out among students for the prevention of use and abuse of narcotic substances. 495 campaigns have been implemented, and 49 of them were for the prevention of the use of alcohol and cigarettes. 95, 745 students have been included at around 400 educational institutions. 4) Specialists at the schools trained to carry out prevention of the use and abuse of narcotic substances. At more than 400 of the schools 1,725 teachers, health care providers, pedagogical counselors, etc., have been trained to work on the prevention of use and abuse of narcotic substances.

At local level

Making no claims to be exhaustive or representative, some of the preventive activities will be presented, oriented to school, carried out at local level and implemented by the RCNS, the PIC and the non-governmental sector.

Dobrich 43

„Municipal program for the prevention of drug use at school” has been directed at developing of a clear, effective and consistent prevention of the use of narcotic substances at the secondary schools. “School for Tennis” long-term preventive and sports program “School for karate” long-term preventive and sports program Demand reduction is done mainly through the development of programs for the prevention of drug use and abuse, through sport and tourism. Thirty two students aged 10-17 train 8 hours per month for nine months each year. The purpose of both the long-term sports programs is to structure and rationalize the spare time of the students, to help for the good upbringing through sport and to neutralize the negative influence of the street.

Shumen 44 A multi-module and permanently functioning educational program including the Municipal Health Center (MHC) and the schools in the villages of Shumen municipality titled “Learn more” started in the month of February. Monthly visits by specialists from the MHC of the students from the 6 to 8 grade in the abovementioned schools are planned according to its activities.

42 Source: Ministry of Education, Youth and Science. The projects specified were implemented in the school year 2009-2010. 43 Source: REPORT ON THE ACTIVITY OF THE REGIONAL COUNCIL ON NARCOTIC SUBSTANCES AND OF THE PREVENTION AND INFORMATION CENTER FOR NARCOTIC SUBSTANCES IN THE TOWN OF DOBRICH -2009 44 Source: REPORT on the activity of the Regional Council on Narcotic Substances – Shumen and of the Prevention and Information Center in 2009.

Sliven 45 In the group of the schools, included in the implementation of “Public program for drug use prevention” in 2009 one more school has been included– a total of 7 schools. The program is aimed at acquiring knowledge and developing skills for healthy lifestyle; avoiding risky behaviour, training in social skills; acquiring socially adaptive behaviour.

The program will be introduced stage by stage in the rest of the schools in the municipality of Sliven, too. During the year past the project for establishing 2 consulting offices for health education according to the requirements of the program was implemented. The work on the “Prevention and anti-aggression” program continues-it is addressed to the children aged 8 -10 years. 12 schools in the municipality work after this program. Health educational module for students and parents. February-2 prevention sessions with students from 7–11 grade; 1 prevention session with parents; May- 3 prevention sessions with students from 7– 9 grade; December - 2 prevention session with students from 9 -12 grade.

Varna 46

”Information campaign for the prevention of drug use at “Sv. Nikolay Chudotvorets” Varna Marine Secondary School (VMSS), the district of Asparuhovo” project. The project was implemented by the “Youth initiative for Varna” not-for-profit association. The aim of the project was to enhance the awareness of the target group (students from 8-11 grade of the “Sv. Nikolay Chudotvorets” VMSS). Through the work on the project contact was made with 900 students, 300 parents, 5 professionals, 47 volunteers and 20 peers. ”Information campaign for the prevention of drug use at the III Environmental and Mathematical Secondary School (EMSS) „Academician Metodi Popov” Project. The project has been implemented by an Association of Varna organizations for addiction prevention. The objective of the projects was to enhance the awareness of the target group (students from 8-11 grade of the III EMSS” Academician Metodi Popov”). Through the work on the project contact has been made with 490 students, 311 parents, 50 teachers and representatives of the school community and 16 peers.

Vratsa 47 This year we have worked with “Vasil Levski” primary school after the “Prevention and anti-aggression” project. The methods were addressed to the age group 1 – 5 grade. This is already the third year that the students have been educated under the program. The methods adapted represent an adapted variant, developed by the “Index” Foundation, on the basis of the continuous work of the Foundation with various international partners in the sphere of the prevention of the use of psychoactive substances. Three schools on the territory of the municipality of Vratsa work under the “Health Education” Program, namely: “Ioan Ekzarh” Language School , “Vasil Kunchov” Secondary Comprehensive School, and “Kliment Ohridski” Secondary School. The students from 8 - 12 grade are the target group of the project presented. The main objective of the program for health education is for the students to acquire knowledge, to adopt positive attitude and to acquire skills for healthy lifestyle, to avoid risky behaviour

45 Source: ANNUAL REPORT on the activity of the Regional Council on Narcotic Substances – Sliven and of the Prevention and Information Center – Sliven in 2009. 46 Source: INFORMATION ABOUT THE ACTIVITIES IMPLEMENTED BY VARNA MUNICIPALITY „PREVENTION OF ADDICTIONS” DEPARTMENT 47 Source: ANNUAL REPORT OF THE REGIONAL COUNCIL ON DRUGS – VRATSA 2009, REPORT on the activity of the Prevention and Information Center 2009

and to show socially adaptive behavior. The health education program comprises 36 units, developed for 8, 9, 10 and 11 grade. These units are structured in 3 modules, which are the same for all the alumni– “Personality and Health”, “Personality and Sexuality”, “Drugs- Risky Behaviour”. Some of the schools have their lessons in the conference room of the PIC. Sofia 48

“Prevention of drug use in the school milieu” Program. Aim of the program: Enhancing the capacity of the schools for the implementation of long-term prevention programs to reduce the risk of psychoactive substance (PAS) use and of the social aftermaths ensuing for the young people – dropping out of school, criminal acts, leaving home etc. Establishing a group of motivated school specialists (teachers, pedagogic counselors, health specialists) who should implement prevention activities on the territory of their schools with the external assistance of the Program team. The Program has been announced with the help of the Regional Inspectorate on Education, Sofia-city, which published the information on its website. Forms for applying have been submitted by 16 schools from the city of Sofia, with 40 representatives. All of them have been approved for participation in the Program. Agreements for partnership between the school and the PIC have been signed. The program covers the school year 2009/2010 and consists of 3 stages: First stage: 5 one-day practical seminars on acquiring experience to apply profound activities and practices in the sphere of the primary prevention; training skills to refer to specialized institutions and motivation in seeking consultation for the students and their parents in cases of risky use of PAS. Second stage: 5 half-day consulting meetings to integrate specific practices at a specific school; working off difficulties from the practical work and sharing the successful practices. Third stage: making a product by the participants in the program addressed to their colleagues at school. In 2009 the first stage of the Program was worked on.

3.1.2. In the family

At national level

In 2008 with the funds of the National Anti-Drug Strategy (2003-2008 ) the National Center for Addictions (NCA) funded “The other names of the addiction (Prevention of drug dependence among adolescent groups and assistance for their parents and friends by the means of art and by applying efficient creative approaches)” project of the “Gulliver Clearing House” Foundation. The activities under the project were implemented in the period between November 2008 and April 2009. The main objective of the project was achieving a higher level of awareness and competence of the young people, of their parents and friends about the risks, the difficulties and the temptations of the drug dependence.

At local level

Varna 49

Within the framework of the “School for parents” program 2 projects have been implemented:

48 Source: ANNUALREPORT 2009, Prevention and Information Center for the problems of addictions- Sofia. 49 Source: INFORMATION ABOUT THE ACTIVITIES IMPLEMENTED BY VARNA MUNICIPALITY “PREVENTION OF ADDICTIONS” DEPARTMENT

• ”Information campaign for the prevention of drug use at “Sv. Nikolay Chudotvorets” Varna Marine Secondary School (VMSS), the district of Asparuhovo” project. The project has been implemented by the “Youth initiative for Varna” not-for-profit association. The objective of the project was to enhance the awareness of the target group (students form 8-11 grade of the “Sv. Nikolay Chudotvorets” VMSS). Through the work on the project contacts were made with 900 students, 300 parents, 5 professionals, 47 volunteers and 20 peers. Within the framework of the project educational trainings have been carried out for peer-teams, educational modules have been developed, tested in controlled milieu, demonstration lessons have been taught to the students and their parents, and a film was shot, with 800 copies. The topics on which the students worked were marijuana, amphetamines, ecstasy, cocaine, heroin, hallucinogen substances, injecting drugs. • ”Information campaign for the prevention of drug use at the III EMSS „Academician Metodi Popov” project. The project has been implemented by Association of Varna organizations for prevention of addictions. The objective of the project was to enhance the awareness of the target group (students from 8-11 grades of the III EMSS “Academician Metodi Popov”). Through the work on the project contacts have been made with 490 students, 311 parents, 50 teachers and representatives of the school community and 16 peers. Within the framework of the project educational trainings have been carried out for peer-teams, educational modules have been developed, tested in controlled milieu, demonstration lessons have been taught for students and parents. The topics on which the students worked were marijuana, amphetamines, ecstasy, cocaine, heroin, hallucinogen substances, injecting drugs.

Sliven 50 The cooperation of the parents is all the more sought for interaction in the educational process, and in particular for the prevention activity: - “Bratia Miladinovi” Primary School–informing the parents about the aftermaths of drug use - “D. Damianov” Humanitarian Secondary Schoo l– Sliven – there were talks with the parents about the risk of the children to get into drug milieu; informing about the changes in behaviour when the children use drugs; - “Hr. Botev” Primary School– the village of Sudievo- work with the parents whose children manifest aggression; - “K. Konstantinov” XI Secondary Comprehensive School– informing the parents about the updated Statute of the School Activity / in relation to the amendments in the Rules on the Implementation of the Public Education Act/ and the sanctions imposed for violations; the cooperation of the community of the parents is demanded.

Turgovishte 51

There have been meetings and talks with the parents of children who had been included in the Public Program for Drug Use Prevention and recognition of healthy lifestyle among the young people – they have been informed about the essence of the Program, and what the purpose was of introducing it. For the parents a book was issued in 2009 – “Drugs and Our Children”. It contains information about the types of drugs, what is their effect, what they should do in case their child has used drugs, and whom they should refer to. The book has been provided to the schools in the town and in the villages to be distributed among parents and students from 7 and 8 grade.

50 Source: ANNUAL REPORT on the activity of the Regional Council on Narcotic Substances- Sliven and of the Prevention and Information Center in 2009 51 Source: REPORT ON THE ACTIVITY OF THE REGIONAL COUNCIL ON DRUGS THE TWON OF TURGOVISHTE FOR 2009

3.1.3. Within the community

At national level

As in the preceding years the State Agency for Child Protection (SACP) continues displaying on its Website useful information with the telephone numbers and addresses of institutions where aid is provided- treatment and rehabilitation of individuals dependent on psychoactive substances, as well as data about the NGOs working on the prevention of drug use. In 2009 the Bulgarian National Television showed two documentaries – “Casting” and “In Order to Live” related to the topic and funded the SACP. When there were meetings with children, parents and professionals, DVD copies of the two films were distributed, as well as posters, printed by the SACP applying the ideas of children in relation to the prevention of addictions. Within the framework of the workshops, seminars and supervision by specialists from the system of child protection the SACP continued to disseminate the manual on drug prevention meant for social workers – “The Known and Unknown Teenager.” Periodically communications have also been prepared for the official website of the SACP.52 The ”Construction of Bulgarian Information Line on Drugs” project is funded by the MATRA program of the Ministry of Foreign Affairs of the Kingdom of the Netherlands, and is implemented by the “Solidarity” association for rehabilitation of dependent individuals. The services offered by the line are: telephone and Internet consulting; current information about the effect and risk of drug use; referring to treatment and rehabilitation programs on the territory of the whole country; hot line; answering machine; services in the Internet milieu, through the website of the project. The total number of the website visits of the Information line for the whole of the country is 61,632. The total number of the unique visits of the website is 46,640. According to the type of drug for which a person has called, the greatest number of calls is for alcohol-– 44%, heroin – 22%, cannabis – 9% and for all the other substances – 25%. The cause for the contact is most often the use of drug by someone else (a relation, a friend, a relative) – 70 % and personal use – 13%. In case someone else has used the drug the greatest number of the contacts are related to drug use by a child – 57% (142). Second come the contacts when a relative has used drugs – 22% (56), third comes the contact when the spouse has used drugs – 15% (37) and last contact has been made because a relation has used drugs – 6% (16).

“Addicted to life. International information campaign for prevention and reduction of the risk related to amphetamine use.” is an international project with the participation of partners from Bulgaria, France, Hungary and Macedonia. It includes the development of information products (www.addicted2life.eu ) and activities for cooperation with the media. Period of implementation – 2009-2010. It is funded by the European Committee.53 The commitments of the Ministry of Physical Education and Sports (MPES) for the implementation of the Action Plan of the National Anti-Drug Strategy 2009/2013 are for the strategic task 1, task 1.5 – subtask a) from the Plan, namely: “Expanding the opportunities for presenting to the children and to the young people attractive ways to spend their spare time”- “Sport for the children in their spare time” Program.

52 Source: Information from the SACP on the implementation of the Action Plan of the National Anti-Drug Strategy 2009 53 Source: Report of the “Initiative for Life” Foundation about the activities and the funds used for them for the fiscal year 2009

This task is implemented through activities aimed at creating suitable conditions for practicing physical education and sports by the children.

Events are also organized presenting the possibility to practice sports, to have full value rest. The social integration of the disadvantaged children form various ethnical groups is also made possible. The main objective of the program was to open up possibilities and to provide conditions for the participation of the children in sports events during their spare time in view of improving their health and physical abilities and preventing the use of narcotic substances. The program was implemented in the period from 01 January to 31 December 2009 . The target of the program were the children from all over the country, who do not practice sports systematically, and the access to the sports exercises was ensured also for the disabled and the disadvantaged children. 214 projects have been approved under the program and 211 of them have been implemented. In comparison to the preceding year the increase is by 7 %. The program has been implemented in 63 settlements in the whole of the country (incl. 53 projects in Sofia). The total number of the children included in the sports exercises of 50 types of sports was approximately 21, 500, incl. 1,970 disadvantaged children this representing an increase of 57% in comparison to 2008. The greatest number of projects were implemented in the administrative regions of Sofia– 53, Veliko Turnovo -18, Varna – 16, Vratsa – 12, Jambol – 11 and Haskovo – 10. Apart from the traditional sports basketball, volleyball, football and swimming, great interest was stirred up in the children by sports like tennis, baseball, softball, cricket, horse riding bowling, sport shooting, rhythmic gymnastics, aesthetic gymnastics, and taekwondo. After completing the activities of the projects, 4,859 children enrolled in the groups for regular sports practicing. In comparison to the preceding 2008 for regular training exercises 1,059 more children enrolled, which is an increase of 22%. The municipal administrations, the regional inspectorates on education, the school managements, the sports organizations and the mass media were partners of the MPES for the implementation of the program. The result of the implementation of the program is of social significance- conditions and opportunities are created for free access of the children to sports exercised during their spare time. For the implementation of the activities under the Program mainly the school base was used (in 82 schools). This represents around 33% of all the sports sites where the Program has been implemented. The funds for the implementation of the program have been provided from the budget of the MPES and amounted to BGN 904, 120 (nine hundred and four thousand one hundred and twenty Bulgarian levs).54

At local level

Veliko Tarnovo 55

“Do drugs control your life” campaign was carried out on the occasion of June 26 th – the International Day to combat drugs, implemented by the Prevention and Information Center for Addictions jointly with the SINDI Program and with the Regional Inspection for Preserving and Control over Public Health in Veliko Tarnovo, the Youth House and youth organizations and included the following activities:

54 Source: Ministry of Physical Education and Sports 55 Source: REPORT ON THE ACTIVITY OF THE REGIONAL CONCIL ON NARCOTIC SUBSTABNCES VELIKO TURNOVO - 2009

- a TV clip was broadcast by the Videosat cable TV and shown on the video wall in front of the municipality in Veliko Tarnovo; - making, printing and distributing a poster and a billboard. The poster was distributed, together with other printed materials on the topic “addictions” at the schools by the members of the “SOS Friends” Addiction Prevention Club; the billboards were placed on the highway Sofia- Varna in the segment between the traffic lights “Praktiker” and “Masiv” next to the Environmental and Mathematical School. - re-issuing and distribution of the CD “Drugs- Touch to Reality”. - press conference for the presentation and launching of the media campaign for the opening of the “Addictions” exposition.

3.2. Selective prevention

3.2.1. Groups at risk

At national level

During the year the Local Committees for combating the antisocial acts of minors and underage (LCCASAMU) identified 237 groups of children and families at risk for using drugs. After assessing the need of intervention for these groups 109 programs for prevention and assistance of the children at risk were developed and applied . In these programs 292 individuals were included.56 In 2009 the State Agency for Child Protection ensured the introduction and the functioning of an all-European telephone number for children at risk- 116 111. In this way Bulgaria became the 14 th member state of the European union to implement decision 2007/698/ ЕО of the European Committee. The national telephone line for children in Bulgaria 116 111 presents the opportunity for consultation, for giving specialized information about the rights of children , for crisis intervention and, if needed, refers to appropriate services and service suppliers. The line is free for the users and provides to the children an accessible mechanism to get help at any time of the day and the night. With the aim of popularizing the National Telephone Line for Children (NTLC)116 111 among the specialists from the system for child protection, a team from the SACP held seminars, round tables, discussion forums and information meetings in 9 cities in the country. At the end of 2009 from the statistical processing of the calls the following conclusions can be made: the greatest number of calls were by children (79 % of all the received calls) teenagers (85 % of all the calls made are by children teenagers). Parents use the line comparatively often (8% of the consultations realized), and they seek information and assistance for the problems of their children. This shows that the parents have information about the NTLC 116 111 and consider it a source of help in their attempts to solve the problems in communicating with their children. On the line cooperation and information are sought mostly for emotional and family problems, and more rarely for problems like violence in the family or at school, or neglect, but these cases are particularly grave and often continue. NTLC 116 111 is recognized as a source of emotional support, source of information about available programs and services supporting children and families, as a well as an accessible channel for signaling about a child at risk not only by the endangered children themselves, but also by concerned adults, for whom the other channels are difficult to access. 57

56 Source: INFORMATION ABOUT THE ACTIVITY OF THE CENTRAL AND LOCAL COMMITTEES FOR COMBATING THE ANTISOCIAL ACTS OF MINORS AND UNDERAGE FOR THE IMPLEMENTATION OF THE ACTION PLAN OF THE NATIONAL ANTI-DRUG STRATEGY 57 Source: Information of the SACP on the implementation of the Action Plan of the National Anti-Drug Strategy 2009

At local level

Varna 58

A program for multi-component prevention of risky behaviour among vulnerable groups of young people (after the method “Mobile work in the community” of ISMO) The program meets the necessities of help, care, communication and guidance when there is a specific problem with the children and their families. New patterns of behaviour and communication are presented, without the necessity for the participants to visit a definite institution. The participation in the program is voluntary. 20 children aged 8–16 years and their families selected according to specific criteria (a history of problematic behaviour of the child at home, at school and with peers; a history of the family situation, etc.) were included in the program. For each particular case a plan for working with the child and with the family was prepared. Psychologists and pedagogues worked with the children. The students and their relations were consulted by a psychologist. The children included in the program were provided the possibility to have many talks on problematic for them topics. This was combined with sports games, acquiring social skills, acquiring skills for adequate communication, etc. At the end of the program the children were convinced that there are other patterns of behaviour and communication with peers and adults; other ways to rationalize the spare time; the trust of the parents has been gained and they stated their wish that their children be again included in such a program. The program was implemented in the period from June 15 th to September 15th 2009 in the “Mladost” district in partnership with the district administration.

Bourgas 59

Within the framework of the “HIV prevention among prostituting men and women” program and in connection with trends observed that some of the prostituting individuals subsequently begin using different narcotic substances prevention is done to them. Target group- prostituting men and women. Activities for the implementation – The prevention is done through presenting information on drugs and dependence individually or in groups. The information is disseminated during the current outreach after the program through brochures and discussions. Results - Around 500 men and women have been informed about the types of narcotic substances and their effect.

3.2.1. Families at risk

At national level

Special priority is given to the work with parents on issues related to the prevention of the use and abuse of narcotic substances on the part of the children at the Local Committees to Combat the Antisocial Acts of Minors and Underage (LCCASAMU). Programs have been implemented on topic “Family- the most reliable barrier against drugs”, “My child does not use drugs”, “How to protect our children from drugs”, “Program

58 Source: INFORMATION ABOUT ACTIVITIES IMPLEMENTED BY THE MUNICIPALITY OF VARNA, ‘PREVENTION OF ADDICTIONS” UNIT 59 Source: INFORMATION ABOUT ACTIVITIES IMPLEMENTED IN THE SPHERE OF PREVENTION OF ADDICTIONS BY THE “DOSE OF LOVE” ASSOCIATION IN 2009

for preventing the use of psychoactive substances”, “Children and drugs- how to talk with them about this” project, “A chance for our children”, etc. 60

At local level

There is no current information regarding the selective prevention in families at risk at local level.

3.2.3. Recreational settings

At national level

There is no current information regarding the selective prevention in recreational settings at national level.

At local level

There is no current information regarding the selective prevention in recreational settings at local level.

3.3. Prevention by indications

At national level

In 2009 the “Listen to the child- improving the prevention and the access to services of children and adolescents, experimenting with and using narcotic substances” Project № BG0011 started, which is implemented under the terms of the signed Agreement № C-39/12.08.2009 between the National Center for Addictions (NCA) and the Ministry of Finance “Management of the Funds from the EC” Directorate – A National Coordination Unit for the Finance Mechanism of the European Economic Area. The project is funded through the Finance Mechanism of the European Economic Area (FM of the EEA). The donor states are: Iceland, the Principality of Liechtenstein and the Kingdom of Norway. The beneficiary for the project is the National Center for Addictions, with partners: the Prevention and Information Center on the problems of addictions – Sofia, the Service on the Problems of Alcohol and Addictions at the municipality in the town of Oslo (Norway), and the Regional Office for South-East Europe of the United Nations Office on Drugs and Crime (UNADC). The main objectives of the project are: • providing specialized services for children and adolescents experimenting with and using drugs and for their families; • enhancing the competence of the professionals and the exchange of information on the problems of dependence; • changing the public attitude; • studying and disseminating good practices and introducing innovative programs. Main activities planned for implementation within the framework of the project: 1. Setting a free national telephone line for consultations and guidance on the issues of the dependence on narcotic substances and alcohol. 2. Holding trainings which include education in: techniques for doing screening, early and short interventions and referral for treatment. The aim is to hold a total of 38 seminars for the whole of the country, in which 950 experts and specialists from

60 Source: INFORMATION ON THE ACTIVITIES OF THE CENTRAL AND LOCAL COMMITTEES TO COMBAT THE ANTISOCAILA ACTS OF MINORS AND UNDERAGE IN IMPLEMENTING THE ACTION PLAN OF THE NATIONAL ANTIDRUG STRATEGY

healthcare, social and educational institutions should participate (GPs, nurses, social workers, pedagogic counselors, etc.). 3. Opening a center for children and adolescents who experiment with or use psychoactive substances and for their families. The center for children and adolescents will be established at the Prevention and Information Center on the problem of addictions – Sofia. With the funds for the project a repair and furnishing will be done of the center, and a team will be organized for the functioning of the center. A program will be developed and implemented for adolescents who experiment with or use psychoactive substances and for their families. The program includes: Work with the adolescents: individual and group consulting; different interventions to help the adolescents develop personality and social skills and emotional competence; creative activities in the spare time (club activities, clubs according to interests, sports, etc); work with parents and with the families of the adolescents: individual and group consulting, educational seminars; constructing and maintaining therapeutic relation with the families of the users. 4. Organizing media campaigns and happenings. Within the framework of the project the following events will be organized: Two press conferences – in December 2009 for presenting the activities of the project and in April 2011 for presenting the results. Two happenings aimed at preventing the use of psychoactive substances among children and adolescents. Within the framework of the project a series of video and audio clips are planned to be made and subsequently broadcast via the different electronic media, oriented to the prevention of drug use. 61

At local level

Sofia

Project: “Integration and better care for the users from the Roma minority” 62 The project emphasizes the education and the participation of young Roma people in the activities for harm reduction among the injecting drug users in the Roma community, as well as the promotion of the health education applying the method of peer education. The funding has been provided by the “Open Society” Foundation, Sofia, and IHRD, New York. 12 groups have been formed with 90 representatives of the Roma community .

3.4 National and local media campaigns

At local level

The campaigns in the mass media in the sphere of drug use practically can be separated into three directions:

Presenting the Annual Reports on the situation in Europe and in Bulgaria of the drug-related problem; Coverage of 26 June - International Day against drug abuse and illicit trafficking; Campaigns and publications on other occasions, related to drug use and trafficking (note : here data may be presented from the documentary study of the articles

61 Source: National Center for Addictions, Methodological Management and Coordination of the Activities for Drug Demand Reduction, Preventive Activities Unit 62 Source: Report of the “Initiative for Health” Foundation on the activities and the funds used for them for the fiscal year 2009

from 2009 related to the word – Drugs, provided by the “Sv. Kiril I Metodii” National Library)

On 05 November 2009 at the „Sofia Press” press club the V Annual Expert Meeting took place for presenting the Annual Report for 2009 of the European Monitoring Center for Drugs and Drug Addictions (EMCDDA) on the situation of the drug problem in Europe and on current comparative data for Bulgaria. The meeting was organized by the National Council on Narcotic Substances, the Ministry of Defense, the State Agency for Child Protection, the Chief Directorate to Combat Organized Crime, the Metropolitan Municipality, the Military Medical Academy, the “Pirogov” MHATEM. Journalists were present from more than 15 media in the country.

4. Problem Drug Use

The following topics will be considered under this section: Evaluation of the prevalence and incidence of problem drug use; Data on problem drug use from non-medical sources ; Patterns of intensive or frequent drug use .

Evaluation of the prevalence and incidence of problem drug use

Indirect evaluation of problem drug use

At national level

There are no new up-to-date details on evaluations of problem drug use at national level.

At local level

There are no new up-to-date details on the evaluation of problem drug use at local level.

Evaluation of the incidence of problem drug use

There are no new up-to-date details on the evaluation of the incidence of problem drug use .

Data on problem drug use from non-medical sources

Problem drug users from sources other than TDI

Data provided by the police

According to the data provided by the Regional Police Directorates, the total number of individuals (users and dealers) registered with the “Drugs” Department in 2009 was 4632, which is 21 % up from the 2008 level (3823) (see Figure 4-1). Out of them 899 (or 19.4 %) were minors or underage.

Figure 4.1 INDIVIDUALS REGISTERED WITH THE “DRUGS” DEPARTMENT (DRUG USERS AND DRUG DEALERS) (in %)

22% 1015 Number of drug users

Number of drug dealers

2767 60% 18% 850 Number of, drug users and drug dealers

Source: Ministry of Interior

According to the data provided by the Police, the number of the drug users is 2767 or 59.7% of the total number of the registered individuals (users and dealers). 543 (or 19.6%) of the dealers are minors and underage. 1,517 (54.8%) are cannabis users, 588 (21.3 %) are heroin users, 62 (2.2 %) are cocaine users and 600 (21.7 %) are users of synthetic drugs: ecstasy, amphetamines, barbiturates. (see Figure 9-2)

Figure 4-2 NUMBER OF INDIVIDUALS REGISTERED WITH THE REGIONAL POLICE DIRECTORATES BY TYPE OF DRUG

1600 1517

1400

1200

1000

800 588 600 600 482 385 400 292 206 214 227 200 62 32 27 0 cannabis heroin cocaine synthetic drugs Number of drug users Number of drug dealers Number of drug users and drug dealers

Source: Ministry of Interior

The number of the individuals both using and dealing in drugs was 1015 in 2009 (compared to 741 in 2008), which accounts for 22 % of the total number of individuals registered (dealers and users). Out of them 263 or 26.0 % were minors or underage. As regards cannabis, the number of the registered individuals (both users and dealers) is 482 (47.5 %); in the case of heroin – 214 (21.1 %), cocaine – 27 (2.7 %), synthetic drugs – 292 (29.4 %).

Data provided by the Ministry of Defense

Registered cases of drug and alcohol abuse for the period 2004-2009 in absolute figures:

• 2004 - 84 registered military men abusing and addicted to psychoactive substances and alcohol. Out of them 11 on regular military service and 73 enlisted soldiers; • 2005 - 23 detected cases of drug use at the military establishments of the Bulgarian Army, out of them 2 enlisted soldiers; • 2006 - 20 detected cases of drug use at the military establishments of the Bulgarian Army, out of them 3 enlisted soldiers; • 2007 - 26 detected cases of drug use at the military establishments of the Bulgarian Army, out of them 23 enlisted soldiers; • 2008 – 8 detected cases of drug use. • 2009 – 3 detected cases of drug use.

In the case of the Bulgarian Army, the identified drug abusers are in the range of 0.01% - 0.08 %, but the rate is many times higher vis-à-vis the population in this age group.

Intensive, frequent, long-term and other patterns of problem drug use

There are no available new data on the patterns of intensive or frequent drug use.

Description of the patterns of use other than those covered by the EMCDDA definition of problem drug use

There are no new current data on the description of the patterns of use other than those covered by the EMCDDA definition.

Evaluation of the prevalence of intensive, frequent, continuous and other patterns of problem use, that are not included in the definition of problem drug use

There are no new current data on the evaluation of the prevalence of intensive, frequent, continuous and other patterns of problem use.

5. Drug-related treatment: treatment demand and treatment availability

The following main topics will be reviewed under this section: Strategy / policy; Treatment system.

Strategy / policy

The International Classification of Diseases, 10th revision (ICD-10), qualifies mental and behavioral disorders related to the use of psychoactive substances as being part of the mental health. The modern concept for their treatment is based on an integrative approach which includes medical, psychological, behavioral and social impact. The treatment of patients, addicted to narcotic substances includes programmes based on medication-assisted treatment (detoxification and medicinal treatment – Naltrexone, Methadone and Substitol) and psychosocial rehabilitation programmes of the type of "Therapeutic Community" and daycare centers. There is a network of treatment facilities and treatment programmes in place in the country, which ensures passage through the individual stages of treatment. A trend in the development and expansion of the network is the increase in the number of the positions in the programmes, that are partially or fully funded from the state and municipal budgets, as well as the provision of a greater number of programmes for medicine free treatment. The policy of the Republic of Bulgaria in the area of reducing drug demand and supply is based on the National Strategy to Combat Drugs for the 2009 –2013 period.

Coordination

With a view to improving the coordination among the different treatment programmes and expanding the opportunities regarding information, the following registers have been established and kept at the National Center for Drug Addictions: Register of health establishments implementing substitution and supportive programmes for drug dependent individuals. Register of the persons applying pre-treatment and rehabilitation programmes. Information on the options for treatment and rehabilitation, referral and consultation is provided by the Information and Consultative Centers in the cities of Sofia and Bourgas. The quick and easy access of the patients to the offered treatment is facilitated by the Card for Treatment in Bulgaria, introduced in 2008, which has been developed and can be found on the website of the National Focal Point for Drugs and Drug Addictions (NFP) 63, and can also be accessed via a link from the website of the National Center for Drug Addictions (NCDA). Information brochures presenting the different treatment options have been developed and will be distributed among physicians, parents and teachers.

Treatment system

63 www.nfp-drugs.bg

Organization and quality assurance

1. Medically assisted treatment Medically assisted treatment is performed only at treatment facilities, registered under the Law on Medical Establishments and includes: A) Treatment of abstinence syndrome (detoxification) – The effective detoxification includes not only medical stabilization of patients and ensuring of safe elimination of abstinence symptoms, but also psychological support and motivation of the patient to continue the treatment under specialized programmes. This is the first phase of the treatment, which is available to the patients in the country. It is provided on in-hospital (to inpatients) or out-of-hospital (to outpatients) basis. The choice of in-hospital or out-of-hospital detoxification is up to a psychiatrist and is governed by: 1. History of severe abstinence symptoms; 2. History of abstinence complications (delirium, seizures); 3. Aggravated somatic condition; 4. Severe depression or risk of a suicide attempt; 5. Supporting environment; 6. Remoteness from or no access to a clinic. In-hospital detoxification is carried out at state psychiatric hospitals, psychiatric dispensaries, psychiatric wards of multi-profile hospitals for active treatment and psychiatric clinics at university hospitals. The following are operational in the country as of 31 December 2009: 12 state psychiatric hospitals (SPH), 12 regional psychiatric dispensaries with in-patient facilities (RPDIF), 14 psychiatric wards of multi-profile hospitals for active treatment, 5 psychiatric clinics at university hospitals. The total number of beds for psychiatric patients in them is 5 268, out of which only 170 are for patients dependent on psychoactive substances. Their distribution is as follows: 120 beds at SPHs, 20 beds at RPDIFs and 30 beds at the psychiatric clinics.

The in-patient treatment of drug patients at state psychiatric hospitals is financed from the budget of the Ministry of Health. When detoxification is at the expense of psychiatric wards of multi-profile hospitals for active treatment and regional dispensaries, it is funded according to the methodology of the procedure for subsidizing reorganized treatment facilities for hospital care with state and municipal participation, approved by the Minister of Health. The number of the in-mates at inpatient treatment facilities diagnosed with “psychic and behavioral disorders caused by use of other psychoactive substances” for the same year was 1 478 (see Figure 5-1). A significant downtrend in the number of in-patients in comparison with previous years is reported.

Figure 5-1

NUMBER OF THE PATIENTS WITH PSYCHIC AND BEHAVIORAL DISORDERS DUE TO USE OF OTHER PSYCHOACTIVE SUBSTANCES (ICD-10, CODE F11-F19) AT THE IN-PATIENT WARDS OF THE PSYCHIATRIC ESTABLISHMENTS IN THE COUNTRY IN THE 1990-2008 PERIOD.

2500

2000

1500

1000

500

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Number 183 195 256 396 598 745 785 852 1003 1120 1049 1706 1362 1792 1497 1578 1971 1966 2,167 1,478

Source of information: National Center of Health Information

Out-of-hospital treatment of abstinence syndrome can be performed at outpatient units of various psychiatric clinics, specialized surgeries at medical centers, diagnostic and consultative centres, as well as outpatient facilities for specialized individual and group medical care. In an inpatient environment in-mates get medical treatment and group or individual psychotherapy is also arranged at some locations. Treatment of emergency cases is free of charge – it is covered by the Centers of Emergency Medical Care (CEMC), which, should the need arise, refer patients to toxicological wards and intensive care units or to other hospital departments. B) Substitution and supportive treatment (agonist and agonist-antagonist treatment) The legal framework regulating the conditions and procedures for implementing substitution and supportive programmes in the Republic of Bulgaria includes: • Law on the Control of Narcotic Substances and Precursors; • Ordinance No 24 of 31 October 2000 on the conditions and procedure for implementing substitution and supportive programmes for reducing health damage to persons dependent on narcotic substances; Substitution and supportive treatment can be performed by using medicinal products (opium agonists and agonists-antagonists) from a list approved by the Minister of Health, namely Methadone and Substitol, and Buprenorphine is to be added as well. In 2009 there were 31 operational substitution and supportive programs in the country with a total capacity of 5610 treatment positions, out of which 4 515 for Methadone

treatment and 1 095 for Substitol treatment. The number of the patients undergoing treatment as of the end of 2009 was 3104 . There are operational programmes in 12 cities in the country 64 . The existing programs are of three types: A) State programs with a capacity of 475 positions. The treatment of the patients included in state programs is free of charge and the medicinal product Methadone is provided by the Ministry of Health. B) Municipal programs with a capacity of 720 positions. 2009 saw an increase in the number of the positions for patient treatment under municipal programmes launched at regional psychiatric dispensaries with in-patient facilities (RPDIF). In 2008 there were 470 positions under municipal programmes in the country, while in 2009 their number went up to 720. The treatment of the patients is free of charge and the medicinal product Methadone is provided by the Ministry of Health. C) Programmes without state and/or municipal participation with a capacity of 4 415 positions

Monitoring and evaluation of the efficiency of 10 substitution and supportive programmes (SSP) were conducted in the country in 2009, out of which 5 programmes in Sofia, 1 programme in Rousse, 1 programme in Varna, 2 programmes in Plovdiv and 1 programme in Burgas. The monitoring and evaluation of the efficiency were conducted on the basis of the developed Instrument for monitoring and evaluation of the efficiency of programmes for supportive and substitution treatment, as well as on the basis of questionnaires and surveys on patients, their parents and relatives seeking feedback on the level of satisfaction with the programme. The following summary can be made on the basis of the monitoring report and the annual reports on the activities performed in 2009. Results achieved: Improved psychological and social functioning of the patients; Used substitution and supportive treatment as a means of preventing the spread of HIV and Hepatitis “В” and “ С” among the population in risk made up of intravenous drug addicts. Retention in treatment and drug use reduction; A decrease in the criminal behaviour of the patients was reported. Main problems and difficulties : Drop out of a large number of patients from the treatment programmes for financial reasons. This is a major issue with all programmes that are not financed by the state and/or municipalities. Difficulties in treating concomitant diseases due to lack of health insurance and patient motivation. Negative attitude of society towards patients participating in the programmes. In 2009 the substitution and supportive programmes were still those with the biggest capacity of positions for dependency treatment (particularly opioid dependency), but the opening of new programmes has slowed down as compared to 2008, there is a trend of increasing the number of the treatment positions in the already functioning programmes, as well as a trend of reducing the number of positions for Substitol treatment at the expense of positions for Methadone treatment. There is a growth in the total number of

64 Source: “Narcotic Substances” Directorate, Ministry of Health

the occupied positions in the substitution and supportive programs as compared to the 2008 data. 2. Psychosocial rehabilitation programmes. Psychosocial rehabilitation of persons suffering from mental and behavioral disorders due to the use of psychoactive substances is a system of activities and care aimed at improving the bio-psycho-social functioning of the individuals and their social integration. Psychosocial rehabilitation and re-socialization of persons addicted to narcotic substances is carried out under 11 rehabilitation programmes with a capacity of 240 positions.

2.1. Psychosocial rehabilitation programmes (of the type of a “psychosocial rehabilitation and integration centre”) – a total of 90 positions 2.2. Daycare rehabilitation programs at the regional dispensaries for mental disease with inpatient facilities – a total of 100 positions 2.3. Long-term programmes for psychosocial rehabilitation (of the type of “therapeutic community”) – 2 programs with a total capacity of 50 positions. 2.4. In-hospital programmes for psychosocial rehabilitation. As indicated by the data in the 2009 annual reports, the total number of covered clients/patients is 487, while the total number of persons that have finished the programmes is 192. The analysis of the National Center for Drug Addictions based on processed programme reports highlights the major achievements, problem areas and trends, namely 65 : Results achieved: Filling of the capacity of positions under the rehabilitation programmes. Retention in treatment by way of group therapy with the clients, social integration and good therapeutic relationship. Curbing of the impulse to use psychoactive substances and longer remission periods of the clients, attained through systematic psychological work and social activities aimed at job finding and educational qualification gaining. Improved functioning in the family and in society manifested in employment, academic engagement and better atmosphere in the family. Development of the spontaneity and creativity of the drug dependent persons, appearance in the public domain in socially acceptable roles: artists, painters, trainers. Trends: Growing demand for rehabilitation programmes in connection with addiction to alcohol, stimulants and gambling. Improvement of the activities of assessing dependent persons and inclusion of additional diagnosing methods. Growth in the staff resources for comprehensive assessment of the personality of the dependant person and development of an adequate therapeutic plan. Expansion of art-related activities and of the work with the family system as a best rehabilitation practice. Problem areas Insufficient or no funding and poor facilities for attaining stability and sustainability of the activities.

2009 Annual reports of the rehabilitation programmes

Treatment system summary. The treatment system develops in line with the concept of the integrative approach to treatment and dependencies. The treatment of patients with dependencies is of two major types: psychosocial rehabilitation and medically assisted treatment. The main features of the treatment system are as follows: Functioning system for substitution treatment (agonist and agonist- antagonist treatment) – there are substitution supportive programmes in 12 cities in the country. Insufficiently developed system for drug-free treatment. The positions under the programmes for drug-free treatment fail to meet the needs of the patients. Insufficient development of programmes for consulting and treating adolescents. The access of drug-dependent individuals to treatment is impeded due to territorial and financial reasons. The treatment system targets mostly the needs of patients with opioid dependencies. The system for treatment and psychosocial rehabilitation established in the country ensures high quality of the services. Access to treatment For the purpose of improving the access of patients to health care three centres for counseling and referral for treatment of dependent individuals and their relatives have been opened – they perform status assessment, counseling and referral for treatment, if necessary. In 2009 a national information line on drugs and alcohol was set up at the “Ambassadors of Hope” Information and Advisory Center – “Solidarity” Association for Rehabilitation of Dependant Persons, which offers information about psychoactive substances and their use, as well as consultation and referral to treatment and rehabilitation programmes on the territory of the whole country. A map of the treatment options in Bulgaria is supported and updated on the web site of the National Focal Point for Drugs and Drug Addictions .

6. Health correlates and consequences

Drug related infectious diseases

HIV/AIDS, viral hepatitis, sexually transmitted diseases and tuberculosis

The presented country data for 2009 have been provided by the “HIV/AIDS Prevention and Control” Programme of the Ministry of Health (MH). The data on the city of Sofia have been provided by the Laboratory at the National Center for Drug Addictions, which specializes in handling drug addicts. The data refer to patients of the State Psychiatric Hospital for Treatment of Addictions and Alcoholism (SPHTAA) and clients under the outreach programmes of the Initiative for Health Foundation and CARITAS from Sofia City.

Concise update on the prevalence of HIV/AIDS in Bulgaria in the 1986 –2009 period

According to the data provided by the National HIV Confirmatory Laboratory, 171 new HIV-positive persons were registered in Bulgaria in 2009.

The distribution of the 171 newly registered HIV-positive individuals according to the mode of infection and the reason for the test is as follows:

1. 74 (43.27%) injecting drug users 2. 32 (18.7%) in-patients 3. 26 (15.2%) homo / bisexual 4. 16 (9.35%) on request 5. 8 (4.67%) partners of persons with HIV infection 6. 4 (2.33%) pregnant women 7. 4 (2.33%) blood donors 8. 1 (0.58%) child born to a HIV positive mother 9. 1 (0.58%) prostitute 10. 1 (0.58%) alien student 11. 1 (0.58%) alien permanent resident in the country (MSM)

The total number of the HIV-infected persons registered since the beginning of HIV status testing of Bulgarians is presented in Table 6-1

Table 6-1

Cumulative Registered number of Year persons with persons with HIV HIV 1986 4 4 1987 41 45 1988 22 67 1989 20 87 1990 4 91 1991 7 98

1992 11 109 1993 12 121 1994 18 139 1995 14 153 1996 34 187 1997 30 217 1998 26 243 1999 27 270 2000 49 319 2001 40 359 2002 43 402 2003 63 465 2004 50 515 2005 83 598 2006 91 689 2007 126 815 2008 123 938 2009 171 1100

SPECIAL TESTS

Subtyping

In 2009 sixty-four HIV-1- positive persons were successfully genotyped. Fragments of the pol gene of the viral genome were sequenced – the protease and part of the reverse transcriptase. The obtained sequences were used for genotyping and comparison with reference sequences in several data bases for the purpose of identifying their subtype: 1. Los Alamos National laboratory, CA, USA, http://hiv-web.lanl.gov 2. Stanford University, CA, USA, http://hivdb6.stanford.edu 3. National Center for Biotechnology Information (NCBI), NIH, MD, USA, http://www.ncbi.nih.gov 4. Rega HIV Subtyping Tool (version 2.0) – Bioafrica, Katolike Universiteit http://www.bioafrica.net/virus-genotype/html/subtypinghiv.html

Phylogenetic analysis was conducted for the first time by creating a phylogenetic tree with the help of specialized software.

It has been found that there are diverse genetic variants of HIV-1 – subtypes and circulating recombinant forms among the carriers of НІ V-1 in the country: 02_AG 3 (6,52%), A (01_AE) 4 (8,33%), А1 6 (12,5%), В 24 (50%), F1 2 (4,16%), G 1 (2,1%), G (02_AG) 2 (4,16%) и NA 6 (12,5%).

Different genetic variants of НІ V-1 are observed with the different risk groups of the population - МSM, intravenous drug users (IVDU) and heterosexual individuals. In the case of MSM, sub-type B is generally prevalent, while in the case of IVDU and heterosexual diffusion there is generic diversity of various subtypes and recombinant forms-CRF.

Tests to diagnose early HIV infection

In 2009 tests were performed, for the second time in Bulgaria, to diagnose early (recent 6 months) HIV infection. 576 serum samples obtained from 170 individuals were tested; 152 of them were part of the 2009 panel of the National HIV Confirmatory Laboratory, i.e.

these were 152 newly registered Bulgarian citizens in 2009. The remaining 18 were related to anonymous individuals identified as HIV-positive in the city of Sofia in 2009.

During the testing of the serum samples of 152 newly registered HIV-positive persons from the 2009 panel early infection was identified with 33 persons or 21.7%.

Their distribution by reason for the test is as follows: 1. homo/bisexual – 43.5% i.e. in 10 serum samples from 23 persons (3 out of the 26 registered persons have no S samples in the 2009 panel); 2. exposed to HIV + 37. 5% i.e. in 3 serum samples from 8 persons. 3. on request – 37.5% i.e. in 6 serum samples from 16 persons. 4. Drug addicts – 21.8.% i.e. in 14 serum samples from 64 persons (9 of the 74 registered drug addicts have no S samples in the 2009 panel.) 5. Other in-patients – 18.5% i.e. in 5 serum samples from 27 persons (5 of the 32 registered individuals have no S samples in the 2009 panel) NB These are persons tested as in-patients, at that three of them have AIDS- related diseases. There is no information on two of them.

The testing procedure involved the Calypte HIV-1 BED Incidence EIA (IgG-Capture HIV- EIA) test and the results of the conducted screening and subsequent confirmatory procedures involving this test were processed by software offered on the web site of the Calypte company (USA).

CONCLUSIONS:

1. A total of 171 new HIV-1-positive Bulgarian citizens were registered in 2009. This is the highest number of newly registered cases over a period of 1 year. A comparison can be made with the previous 2 years, 2008 and 2007, where they were 123 and 126 respectively.

2. The number of the newly identified injecting drug users is the largest – 74 (43.27%), followed by that of in-patients – 32 (18.7%), homo/bisexuals – 26 (15.2%) and persons tested on their request – 16 (9.35%).

3. The subtyping of the HIV-1 sequenced during the year once again confirmed the huge genetic diversity of the HIV circulating in the country, at that 50% belong to subtype B, followed by A and other recombinant forms. A striking fact is that subtype B is mostly identified among MSM, while in the case of heterosexual infections there is considerable genetic diversity.

4. The tests to diagnose early HIV infection among those that have registered in 2009 revealed that 43.5% of the homo/bisexual individuals are with early (recent 6 months) HIV infection, and so are 37.5% of those exposed to HIV-positive persons, 37.5% of those that took the test on their request, and 21.8% of the newly registered drug-addicts.

Test results of drug users in Sofia

The Laboratory of the National Center for Drug Addictions tests addicted persons for the following markers: - HIV ½ antibodies – to diagnose HIV infection;

- HCV antibodies – to diagnose viral hepatitis C; - HBsAg – to diagnose viral hepatitis В; - TPHA – to diagnose syphilis.

Tests and positive results in 2009

Table 6-2 presents the total number of the persons tested in Sofia in 2009 and the positive results obtained at the National Center for Drug Addictions.

Table 6-2

SEROLOGICAL TESTS OF INJECTING DRUG USERS 2009

TAST TYPE NUMBER OF POSITIVE TESTS RESULT HIV antibodies 960 26 2.71% HCV antibodies 955 584 61.1% HbsAg 941 55 5.85% Syphilis 950 46 4.84%

Source: Laboratory at the National Center for Drug Addictions

The injecting drug users (IDUs) tested at the Laboratory of the National Canter for Drug Addictions are patients of the State Psychiatric Hospital for Treatment of Addictions and Alcoholism (SPHTAA) and clients of outreach programmes for drug users – CARITAS and “Initiative for Health”. The testing procedure is voluntary and free of charge and includes ex-ante and ex-post counseling.

1. ANTI HIV 1/2

Out of a total of 960 tested IDUs: - 512 are clients of the Laboratory of the NCDA (on treatment at the SPHTAA or other programmes and centers), 8 of them, or 1.56%, are HIV -positive; - 109 are clients of the “CARITAS “program, 7 of them, or 6.42%, are HIV -positive; - 339 are clients of the “Initiative for Health” Foundation, 11 of them, or 3.24%, are HIV - positive .

Out of the 26 confirmed carriers of HIV injecting drugs, 22 are newly diagnosed: 3 people have been tested before, but no confirmed case has been reported by the National Confirmatory Laboratory for HIV. A client of a non-governmental organization (NGO) has refused to emerge from anonymity. The ratio of the HIV-positive males to HIV-positive females is 53.84% to 46.15%. Such a ratio is reported for the first time since 1995. In the previous years the number of the HIV- positive males was substantially higher than that of the females. A possible explanation of this shift in the ratio is the fact that there is a larger number of tested female IDUs, who offer sexual services in return for payment and thereby increase the risk of acquiring sexually transmitted infections. It is reported that the 25-34 age group accounts for the highest rate of HIV-positive individuals. This group has sustained the highest percentage of HIV-positive persons for the past few years.

All 26 HIV-positive individuals diagnosed at the laboratory of NCDA are also carriers of the virus of hepatitis C, while 3 of them have three co-infections: HIV, hepatitis C and syphilis, and 1 has HIV, hepatitis C and hepatitis B.

2. HBsAg

The total number of the tested persons is 941, 55 of them, or 5.85%, are positive; - 494 clients of NCDA - 25 positive ones or 5.06% - 109 clients of CARITAS - 6 positive ones - 5.50 % - 339 clients of the “Initiative for Health” Foundation, 24 positive ones - 7.10% We can note that the tendency of limited prevalence of the hepatitis B viral infection is sustained and that for the injecting drug users it is within the range of the average proportion for the country.

3. ANTI HCV The total number of the tested persons is 955 , out of thwm 584 or 61.1% are positive: - 507 clients of NCDA - 381 positive ones or 75.14% - 109 clients of CARITAS - 44 positive ones - 40.36 % - 339 clients of the “Initiative for Health” Foundation, 159 positive ones - 46.90%

The analysis outlines a tendency of a growing number of bearers of the virus of hepatitis С since 2007. In the past three years this trend has also been confirmed by the highest percentage of HCV carriers in the age bracket under 25 (see ST 9). For 2009: - Among the tested persons aged under 25 the rate of the infection is 62.46 % - Among the tested persons aged between 25 and 34 the rate of the infection is 58.83% - Among the tested persons aged over 34 the rate of the infection is 64.83%.

LEVEL OF INFECTION WITH HEPATITIS С VIRUS OVER THE PERIOD 1995-2009

1400

1200

1000

800 tested positive 600

400

200

0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Laboratory at the National Center for Drug Addictions

4. SYPHILIS A total of 950 IDUs have been tested, 45 persons, or 4.84 % have proved positive after a TPHA test . In the recent 3 years there has been a lasting tendency of decline of the cases of injecting drug users infected with syphilis. Until 2007 the rate of the intravenous drug addicts suffering from syphilis was about 10% of the tested individuals. Out of the total number of 960 tested injecting drug users 3 are co-infected with HIV, hepatitis С and syphilis,1 with HIV, hepatitis С and hepatitis B; 1 with hepatitis С, B and syphilis and 45 are with two co-infections each. It is evident from these data that the number of the individuals with two or more co-infections is 50 or 5.21 % of all tested persons. The number of the IDUs with more than one infection has been on the rise among the injecting users in the past 5 years.

The following can be observed on the basis of the results:

1. The level of the HIV infection continues to be low, but in the past four years it has marked a stable uptrend among the injecting drug users .

Prevalence of HIV among injecting drug users over the period 2005-2009

% of HIV -positive IDUs

2. The rate of the hepatitis B infection is sustained at about 5% (5.64%), which has been a constant value for 10 years now and is comparable to the general hepatitis C morbidity in the country. 3. The rate of those infected with hepatitis C virus of all the IDUs tested in Sofia is 61.10%. It can be noted that there is an uptrend in the infection rate , 4. The 2007, 2008 and 2009 data indicate that the number of the injecting drug users with two or more co-infections is still on the increase .

Morbidity rates of other infectious diseases

There are no new data available regarding morbidity rates of other infectious diseases.

Behavioural data

There are no new details available regarding behavioural data.

Deaths related to drug use and mortality rate among drug users

Deaths related to drug use

The statistical survey of deaths by cause is based on the medical death certificates completed by the physician, who has ascertained the death. Since the beginning of 2005 Bulgaria has applied the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems of the World Health Organization.

Compilation of a death notice Pursuant to the Civil Registration Act (CRA), civic status acts are official written documents. Those of them that bear relevance to deaths by cause are the death notice, the death certificate and the birth certificate. The death notice is compiled at: - The healthcare establishment where the death has been ascertained; - The municipality or the mayor’s office (region), when a death certificate has been compiled by virtue of a court ruling for ascertaining the death, as well as when a death certificate is produced as per Art. 65(2), 67(3), 72(3) of CRA. The medical worker who has ascertained the death compiles the notice by completing its part “medical certificate of death”. The physician enters in the medical certificate the immediate cause of death, the foregoing and concomitant conditions or diseases and the main (underlying) cause of death. The quality and credibility of the information on the death by cause are largely determined by the precise and accurate entry of the causes for the death.

Codification of the causes of death The codification of the causes of the death is performed in compliance with the International Statistical Classification of Diseases and Related Health Problems, 10 th Revision. When the certificate of death contains just one cause of death, the codification is relatively easy and smooth. In the majority of cases, however, two or more pathological conditions contribute to the death. In accordance with the requirements of the World Health Organization and the instructions on compiling death statistics tables by cause the so called underlying cause for death is codified. It is defined as “the disease or trauma that sets the beginning of the chain of morbid events that have directly led to the death, or the circumstances of the accident or violence that have caused the lethal trauma.” It is presumed that the physician completing the medical certificate of death is in a more favourable position than anyone else to decide which disease or pathological condition has actually caused the death and to indicate which preceding states, if any, have brought about this condition.

The Ministry of Health issues guidelines for encoding the causes of death in accordance with ICD. The codification of the causes for death is carried out by physicians who work for the Regional Healthcare Centers and who are duly trained to implement the requirements of ICD. When encoding the cause of death the physician uses the medical certificate of death. The three-digit code of cause is used when codifying the cause of death. This, in turn, limits the possibilities for analyzing data related to any poisoning brought about by narcotic and psychodysleptic (hallucinogenic) or psychotropic medicines.

Definition In accordance with the EMCDDA requirements (The DRD-Standard, version 3.0) the codes under ICD – 10, that have to be taken into account with regard to poisoning (accidental, intentional or of undetermined intent) are coupled with T- codes to characterize the type of the substance. Т- codes are part of class ХІХ : Injury, poisoning and certain other consequences of external causes. All deaths whose causes are referred to this class are also extended to class ХХ External causes of morbidity and mortality . That is, the cause is classified as a medical cause, on the one hand, and as an external cause, on the other hand, depending on its nature (transport accidents, injury, poisoning, etc). The encoding of the cause at level 4 sign of T- codes (medical cause), makes it possible to specify the type of the substance that has caused the poisoning with a narcotic or psychodysleptic substance (opium, heroin, methadone, etc.). Since Bulgaria applies the three-digit code under ICD, Tenth Revision, it is impossible to identify this substance on the basis of the information available to the National Statistical Institute (NSI). In this sense, according to the EMCDDA requirements, a combination with Т- codes is impossible. In line with the WHO recommendations on the development of the data on deaths by cause, the inclusion of just one code from the two classes necessitates that preference should be given to the code in class ХХ External causes of morbidity and mortality , namely, the codes to be chosen are X and Y. According to the DRD-Standard, version 3.0, when it is not possible to combine X - and Y - codes with T - codes, the alternative procedure is to include the deceased referred to some additional causes included in the class of External causes for morbidity and mortality. However, the analysis of the data indicates that the evaluation of mortality associated with drug use, provided that all these causes are taken into account, is considerably overrated. Taking into account the total number of the deaths caused by Poisoning by narcotic and psychodysleptic (hallucinogen) agents (Т40) and Poisoning by psychotropic medications, not elsewhere classified ( Т43), which does not differ substantially from the number of deaths of causes X41, X42, X61, X62, Y11, Y12, we accepted that the evaluation thus obtained would not differ significantly from the one that would have been a fact, had the combination with the T-codes been possible. After completing the analyses, we agreed that the data on the deaths due to the causes listed below should be used in the tables annexed to the report and to this paper for the purpose of drug-related mortality:

F11-F12, F14-F16, Mental and behavioral disorders F19 X41 Accidental poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified X42 Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified X61 Intentional self-poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified X62 Intentional self-poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified Y11 Poisoning by and exposure to antiepileptic, sedative- hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified, undetermined intent Y12 Poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified, undetermined intent

2009 deaths by cause The total number of the 2009 deaths related to the use of narcotic substances is 38 or 0,5 per 100 000 inhabitants. Compared to the previous year, the mortality rate has gone down by 48.4 %. Over the entire period under review – from 1990 till 2008 – the ratio between dead men and dead women is in favour of men, at that in 1993 and 1996 all the individuals who died of the causes listed in the definition were men. In 2009 the number of the males who passed away as a consequence of drug use was 33 or 86,8 %. The number of the females who died of the same causes was 5 or 13,2%. The mortality rates are respectively 0,9 per 100 000 males and 0,13 per 100 000 females.

Drug-related deaths in Bulgaria over the 1990 - 2009 period by gender

100 % 90

60 50 Females 40 Males

0 1990 1991 1992 1993 1994 19951996 1997 19981999 2000 2001 2002 2003 2004 2005 20062007 2008 2009

The deaths-by-age data indicate that the largest number of drug-related deaths, in line with the applied definition, goes to the 25 – 29 age brackets: 14 cases. 87% of all cases are deceased persons aged between 15 and 34. There is not a single case of death among the persons aged under 15 or in the age groups of 35 – 39, 45 – 49, and 60 – 64. Merely 5% of the deaths (just 2 cases) are among individuals aged over 55.

Drug-related mortality rates by age group in 2008 and 2009

per 100 000 persons 6.00

5.00

4.00 2008 3.00 2009 2.00

1.00

0.00 <15 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 >=65

The average age of the persons who expired in 2009 as a consequence of drug use was 30,9 years, which is down from the 2008 level (33,6 years). It is considerably lower for males – 28,6 years, while in the case of females it is 46,4 years. When analyzing the data, however, one should bear in mind the small number of cases, particularly with regard to deceased females. The difference is significant, if we analyze the indicator median age 66 of the deceased persons. In 2009 it is 24 years, i.e. half of the persons, who passed away of drug-related causes, were up to 24 years old. The median age for males is 24 years and for females 44 years. In 2009 there were no substantial changes in the pattern of deaths by cause. There was only one man who died of a cause referred to class V of ICD - 10 Mental and behavioural disorders (F15 Mental and behavioural disorders due to other stimulants). All other death cases are caused by External causes for morbidity and mortality. In 2009 once again the largest relative share was that of the persons, who died of Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified (Х42) – over half of all drug-related deaths (52%). Almost all of them are males (19 out of 20 cases of deaths of that cause). The second position in the pattern of deaths is held by Poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified, undetermined intent (Y12). This cause is written and coded as an underlying cause of the death of 21% of the drug-related death cases. All deaths of that cause occurred among men (8 cases). Intentional self-poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified (Х61) was the cause of death of 5 persons (13%) in 2009. As in previous years, this is the only cause where the number of deceased females prevails – 3 cases out of a total of 5. This is the leading drug-related cause of death among women according to the definition applied.

66 Median (median value) is the value, that is in the middle of the rank order of values

Pattern of drug-related deaths in 2009

3% 5% 21% F X41 X42 3% X61 3% X62 Y11 Y12 13% 52%

Accidental poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified ( Х41) – this is the qualification of the cause of death of two males out of all persons who died as a consequence of drug use. Depending on the place of death, drug-related deaths are distributed as follows: o at home – 34,2 % o at a healthcare establishment – 23,7 % o at the workplace – 2,6 % o elsewhere – 39,5 %. From a regional perspective the data indicate that in 2009 the largest number of drug- related deaths occurred in the district of Plovdiv – 13 out of all 38 cases, or 34,2 %. Five persons (13,2 %) passed away in Sofia, the capital city. The districts of Varna and Blagoevgrad rank third with 3 deceased persons each (7,9 % each). Nearly two thirds of the drug-related deaths are concentrated in these districts in accordance with the definition used (63,2%). The rest of the districts where such cases occurred were Pazardzhik, Pleven, Sliven, Burgas, Veliko Tarnovo, Vratsa, Dobrich, Kardjali, Montana, Silistra and Yambol.

Mortality among drug users and causes of death

There are no new data available on mortality of drug users and causes of death.

7. Responses to health correlates and consequences

Prevention of drug-related emergency cases and reduction of drug-related deaths

Another training seminar on the topic ‘Prevention of Overdose among Opiate Addicts’ was conducted in 2009. The seminar was organised by the Initiative for Health Foundation, as part of the implementation of the Save a Life Project financed by the National Centre for Addictions, in fulfilment of Strategic Task 4 ‘Limit the spread among drug abusers of diseases which have an impact on society: blood-transmitted infections, tuberculosis, sexually transmitted diseases’, Task 4b of the Action Plan ‘Reduce the number of drug- related incidents and deaths' of the National Strategy to Combat Drugs (2006-2008).

The seminar is intended for outreach teams working under programmes carried out in the field of reducing the harm of injecting drug use to prevent overdose, since the services offered by these programmes are permanently being enriched and adapted, depending on the changing scene of use. Lecturers at the seminar were: Jöerg Steinmetz – Germany, Reader Margarita Gesheva, MD, PhD, head of department at the Toxicology Clinic of the ‘Pirogov’ University Multiprofile Hospital for Active Treatment and Emergency Medicine (MHATEM) – city of Sofia and Violeta Bogdanova, head of unit ‘Methodological guidance and coordination of activities for reducing social and health harms, with a laboratory’ at the National Centre for Addictions (NCA).

There were 27 participants in the training seminar, of which 22 outreach workers from the towns of Sofia, Burgas, Blagoevgrad, Varna, Pernik, Pleven, Pazardzhik, Plovdiv, Ruse and Kyustendil, and 5 NCA experts.

The aims of training were: • To raise participants’ knowledge of matters of overdose; • To improve skills of effective communication with clients; • To help participants acquire practical experience in dealing with overdose cases – effective and ineffective work techniques; • How to work with clients in terms of their motivation for joining an overdose prevention training; • Exchange of information and experience between teams.

Major seminar topics:

1. Mr Jöerg Steinmetz conducted training in the following problem fields: • What is an ‘overdose’; • Risk factors for overdose; • Methods of work on overdose prevention; • Overdose symptoms; • How to respond in cases of overdose; • How to talk on the phone when calling an ambulance and how to communicate with the Centre for Emergency Medical Care team; • What can be done while waiting for the ambulance to arrive;

• What shouldn’t be done while waiting for the ambulance to arrive; • How and when is Naloxone used; • How to work with a client who has experienced an overdose; • First-aid techniques in a case of overdose.

2. Dr Margarita Gesheva dwelt on the following topics: • The history of psychoactive substances; • When and how is Naloxone used in a case of overdose, and who is it used by; • New trends in the development of the alcohol addiction treatment.

3. Mrs Violeta Bogdanova familiarized the seminar participants with : • Particularly dangerous infections transmitted through injecting drug use; • Report of the European Monitoring Centre for Drugs and Drug Addictions (EMCDDA) about cases of infection with Clostridium botulinum and Clostridium novyi through injecting drug use; • Clinical picture with the different forms of infection transmitted through injecting drug use, treatment and prognosis.

A part of the project are also three trainings conducted with the target group in July, in the framework of planned and performed activities on approbation of training methods for injecting drug users training in prevention and coping with overdose.

Altogether 15 persons took part in the training, of which: - 4 women between the age of 18 and 27 who inject drugs intravenously; - 11 men between the age of 21 and 39 who inject drugs intravenously.

The training ran in two modules – with a theoretical and a practical part. The themes the participants were made acquainted with were: - overdose symptoms - complications in case of overdose - how to contact the emergency and urgent care service - how to give first aid in case of overdose - overdose prevention technique - familiarization with the Naloxone drug and ways to apply it

The practical part consisted of training in how to check for breathing and pulse, artificial respiration and heart massage. The trainees acted out the first aid techniques. Then 3 study films were shown to the trainees, of which 2 were about overdose and one about Naloxone. All the participants were given brochures about giving first aid in case of overdose.

Patients with acute poisoning as a result of drug abuse, who are hospitalised in the Toxicology Clinic of MHATEM Pirogov and are motivated for treatment, are put under the following therapeutic scheme with an average duration of 10 days after the acute intoxication has worn off or has been overcome:

1. Detoxification and depuration

2. Anti-abstinence treatment -sudden withdrawal of the psychoactive substance -administration of tranquilizers -administration of antidepressants -administration of neuroleptics with sedative and anti-abstinence effect

-administration of thymostabilizers

3. Hepatoprotective treatment

4. Cerebroprotective treatment

5. Treatment with vitamins

6. Symptomatic treatment: hypnotics other than benzodiazepins, non-narcotic analgetics for patients with opioid dependence.

7. Rehabilitation treatment

There are no deaths registered of patients who have been admitted with an overdose of heroin , regardless of the severity of the clinical state (including patients with no breathing). This is due to the resuscitation and the adequate antidote treatment – bolus doses of naloxone. A part of the patients leave the clinic immediately after resuscitation of their vital functions – absolute denial of treatment 67 .

Prevention and treatment of drug-related infectious diseases

Prevention

The prevention of drug-related infectious diseases is also an integral part of the two basic documents adopted by the Council of Ministers of the Republic of Bulgaria: National Programme for Prevention and Control of Sexually Transmitted Infections in the Republic of Bulgaria for the Period 2008-2915 and National Strategy to Combat Drug Addictions (2009-2013). A programme for tuberculosis prevention and control, co-financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria, has been under way since 2007. In the Action Plan under the National Strategy to Combat Drug Addictions, activities on prevention of drug-related infectious diseases are described as Strategic task 4:

Task 4.2. of the Action Development of programmes and services for reducing the Plan spread of drug-related diseases which have an impact on society: HIV/AIDS, hepatitis B and C, sexually transmitted diseases and tuberculosis Subtasks: a) Development and provision of steady functioning programmes for exchange of needles and syringes, distribution of condoms; b) Development of screening activities and voluntary testing /including outreach/ of blood-borne and sexually transmitted diseases, pre- and post-test counselling and referring to specialised treatment; c) Creation of possibilities for timely medical assistance and treatment of drug users for co-occurring infectious diseases; d) Carrying out of vaccination campaigns and programmes for hepatitis B and tuberculosis for drug users Goal: Keeping a low level of the prevalence of HIV/AIDS and reducing the level of prevalence of other infectious diseases among drug users

67 According to data from a report about drug addicted patients who were given treatment at the Clinic of Toxicology of Pirogov MHATEM for 2009.

All the organisations working outreach submit their projects to the medical council of the National Focal Point (NFP), in accordance with Regulation No 30 dated 20.12.2000 of the Minister of Health.

In 2009, ten non-profit organisations developed an activity on the prevention of HIV/AIDC, hepatitis B and C among injecting drug users and they obtained a positive opinion from the NFP for implementing these activities, namely the Programmes for outreach work, exchange of needles and syringes, and for doing tests for blood-borne and sexually transmitted infections. These programmes are implemented by non-government organisations within the frames of Component 4 ‘Keeping a low level of HIV prevalence among intravenous (I.V.) drug users’ of the Prevention and Control of HIV, Malaria and Tuberculosis’ financed by the Global Fund as follows: ‘Initiative for Health’ Foundation – Sofia ‘Panacea’ Foundation – Plovdiv ‘Dose of Love’ Foundation – Burgas The Bulgarian Red Cross – Kyustendil The Bulgarian Red Cross – Ruse ‘For Better Psychic Health’ Foundation – Varna P.U.L.S. Foundation – Pernik ‘Adaptation’ Foundation – Blagoevgrad Crime Prevention Fund – Initiative and Civic Responsibility (IGA) – Pazardzhik ‘Social and Health Alternatives’ Foundation – Pleven The programmes provide for exchange of needles and syringes, of condoms and lubricants. Also, under these programmes injecting drug users (IDUs) are provided with information materials, referred to and motivated for treatment, etc.

Apart from the National Programme for Prevention and Control of HIV and Sexually Transmitted Infections in the Republic of Bulgaria, activities related to reducing the harm from drug use are carried out by the CARITAS Catholic organisation. There are five low-threshold centres for IDUs in the country. The mobile surgeries supported by 5 non-government organisations under Component 4 and 2 by CARITAS in Sofia and Burgas.

Counselling and Testing

HIV/AIDS testing in Bulgaria is free, voluntary and bound by the person’s informed consent. The laboratory at the NFP is the only one created to provide services to drug users. Pre- and after-test counselling is ensured for IDUs. The tests for these analyses are provided by the Ministry of Health under the National Programme for Prevention and Control of HIV and Sexually Transmitted Infections in the Republic of Bulgaria. Health insured addicts may also have the tests done through the health insurance system in the diagnostic centres and laboratories.

In 2009 19 surgeries for anonymous and free counselling and testing for HIV/AIDS continued their work in the big towns of the country.

No hepatitis B and hepatitis A vaccine has been administered to drug users in Bulgaria since 2000. Free and compulsory hepatitis B vaccination has been done to all newborn children since 1992.

Treatment

All persons infected with HIV, as well as those ill with AIDS have tests done and get treatment free of charge at the specialised department of the Infectious Diseases Hospital in Sofia, as well as at the infectious disease departments treatment of AIDS four other

specialised departments in different big towns. Antiretroviral treatment is provided for all infected persons who need it. As of 30.09.2009, all of the 300 people in need of treatment are included in a triple antiviral therapy and altogether 504 persons have been included in the registers for tracing 68 . Free and immediate treatment is provided for opiate addicts in the methadone maintenance treatment programme at the State Psychiatric Hospital for Treatment of Addictions and Alcoholism – Sofia and municipal programmes in Sofia, Plovdiv and Varna.

The treatment of opiate addicts infected with hepatitis C is funded by the National Heath Insurance Fund (NHIF). According to the NHIF requirements, drug addicts can be included in an interferon treatment programme provided they have not used drugs for 12 months. Health insured person who follow a methadone substitution and maintenance treatment are not included for treatment. This contraindication continues to limit the possibilities for treatment of addicts. The decision to start antiviral treatment is only made at specialised clinics or departments of gastroenterology that have been approved by the NHIF. In these clinics or departments there is a NHF-approved committee. It is only this committee that may issue an expert opinion for starting an antiviral treatment. A written statement of permitting this treatment is issued by the same committee or another gastroenterologist who has a contract with the NHIF. The antiviral treatment may begin after discussing the alternatives, the adverse drug reactions, the benefits and risks of therapy. The therapy may only start with the addict’s written consent. An important condition to apply is the regularly paid health insurance and social security contributions. The treatment approved by the NHIF takes place at the clinics of gastroenterology of different hospitals in Sofia and the data available has not been confirmed. Treatment of hepatitis B in its acute and chronic form is only assessable for health insured addicts.

Treatment of Syphilis is regulated and it is carried out at the dispensaries of dermatology and venereology in the regional towns of Bulgaria and it is free.

Responses to other health consequences among drug users

Psychiatric and somatic co-morbidity

A part of the patients participating in substitution and maintenance programmes have some co-occurring psychiatric and/or somatic disorders which are either caused by drug use or are independent of it. Therefore the psychiatric and somatic state of addicts joining the programmes is an inseparable part of the process of being included in a similar kind of treatment. The check for suicidal thoughts is obligatory, too. If the symptoms of a specific disease have been caused by drug use, an on-going treatment after terminating the use is normally not required. It is possible that in the evaluation some of the patients may appear to need focused, short-term farmacotherapy, psychotherapy or both. A lot of patients however may have simultaneous existence of endogenous psychiatric disorders which require long treatment. Very often, after the inclusion of addicts in treatment programmes, somatic disorders that have been neglected so far occur, including hepatitis (mostly hepatitis C). Hospitalisation or continuous treatment might be needed. A big part of the patients have dental problems as well.

68 Source: Ministry of Health, HV/AIDS Control - http://www.aidsprogram.bg/static_info1.php?main=data

In compliance with the guidelines for good clinical practice in the field of substitution treatment, proposed in Bulgaria, the following procedures are applied in cases of established psychiatric and/or somatic co-morbidity. 69 : • Refer the patient for treatment to a primary care physician, to an urgent and emergency care consulting room or to a hospital. • Test or send for testing for blood-borne and sexually transmitted infections • Identify severe psychiatric disorders that may need an immediate intervention. • Identify chronic psychiatric disorders, refer the person and provide the necessary therapies.

69 Source: Guidelines for good clinical practice in substitution treatment, National Centre for addictions, Sofia, 2008

8. Social correlates and social reintegration

Social exclusion and drug use

Social exclusion among drug users

According to data of Annual Reports of the programmes for Methadone and Substitol substitution and maintenance treatment in Bulgaria for 2009, the total number of patients participating in them is 2915 70 (in 2008 they were 2 543) . Those who have declared unemployment are 816 (27.99 %) 71 , 68 less people than in 2008 when they were 884 (34.76 %) of all the patients included in such programmes. On the background of decreased unemployment among the patients in the above programmes, a question of interest is the registered increase in the number of addicts without health insurance. For last year they were 1029 (35.30 %) 72 , while in 2008 they were 867 persons (34.89%) 73 .

The observation made could find its logical explanation in the assumption that addicts who found a job in 2009 work without having an employment contract. The decrease of unemployment may also be due to a self-declared positive employment status by the participants in the substitution and maintenance programmes in order to avoid everyday visits to the programme receive the drug concerned.

Data of the monitoring system for looking for treatment in Bulgaria for 2009 shows that the number of drug addict unemployed included in different treatment programmes was 548 (28.69 % of a total of 1910 patients registered in the system), which is by 300 less in comparison with 2008, when they were 844 (42% of all 2009). The number of unemployed Bulgarians is 506 74 (754 75 in 2008). Unemployed addicts of Roma origin during the past year were 27 persons 76 (83 77 for 2008 г.), and those of Turkish origin – 8.

In terms of the health insurance indicator, the values are as follows: 744 78 patients without health insurance (38.95 % of all persons registered in the system), where 564 of them had health insurance contributions until 2009 and 180 have never been health insured. In 2008 the total number of uninsured patients was 828 (41.2% of the total number). The number of uninsured Bulgarians in 2009 was by 68 less (631) than in 2008 (699). Ninety persons among the addicts of Roma origin are without health

70 Data is from 28 programmes out of a total of 30 71 Data is from 28 programmes out of a total of 30. They are calculated on the basis of the number of patients who remained for treatment at the end of 2009 72 Data is from 28 programmes out of a total of 30. They are calculated on the basis of the number of patients who remained for treatment at the end of 2009 73 Data is from the Annual Reports of 23 Methadone and Substitol substitution and maintenance programmes for 2008. With 9 of these programmes the number of unemployed and uninsured persons is calculated on the basis of the total number of patients who participated in the programmes in 2008. With the rest, the number of the unemployed and uninsured is calculated on the basis of the patients who remained for treatment at the end of the year. 74 Concrete data is based on valid answers, totally 1855 75 Concrete data is based on valid answers, totally 1980 76 Concrete data is based on valid answers, totally 1855 77 Concrete data is based on valid answers, totally 1980 78 Concrete data is based on valid answers, totally 1563

insurance, which is by 27 less than in 2008 (117 persons) 79 . The uninsured people of Turkish origin for 2009 were 13 .

In 2009 the people with no permanent residence were 117 80 (6.13 % of the total number), 101 out of them were Bulgarians, 9 of Roma origin and 7 of Turkish origin. The larger part of the addicts with no permanent residence were men (95), women were 22.

Drug use among socially excluded groups

Drug use among homeless children and young people

Deriving from the understanding of homelessness as a temporary crisis and not as a permanent unchangeable phenomenon, the activities of the Centre include: outreach work; social and psychological work; distance work with young people staying at investigation arrests and penitentiary establishments; Youth Committee Programme, Programme for work with young parents; Legal consultations; Training in social skills; Skills development studios; Work with the children of young people who lead a street life; Work on raising the public attention and understanding, etc.

The total number of children and young people the centre worked with in 2009 is 248. According to data from the centre for 2008, their clients were over 250 children and young people .

Thirty-seven of them use drugs, which is 8 persons more compared to 2008, when they were 29. Seven persons are under 18 (5 boys and 2 girls) and 30 are above 18 (23 boys and 7 girls). In 2008 11 persons (8 boys and 3 girls) were clients of the centre until they were 18 years old and 18 persons (16 boys and 2 girls) were over 18.

In 2009, the tendency was preserved among the teenagers up to 18 for the number of volatile substance users to be the greatest (4 people), regardless of the distinct decrease in the value in comparison with 2008 (10 persons). The tendency for the greater part of the young people who are over this age to use heroin is steady, too . Unlike 2008 however the young people using heroin are 17 more than those in the past year – 10 for 2008 and 27 for 2009 (see Table 8-1) .

Table 8-1

DRUG USE AMONG YOUNG PEOPLE UP TO AND OVER 18 IN 2008 AND 2009

Kind of Up to 18 years Over 18 years Up to 18 years Over 18 years substance of age of age of age of age 2008 2008 2009 2009 glue 10 5 4 1

heroin 1 10 3 27

synthetic 0 3 0 2 drugs

Source: Daytime centre 16+, Children and Teenagers’ Association

79 Concrete data is based on valid answers, totally 1980 80 Concrete data is based on valid answers, totally 1785

Daytime care is provided for children between 3 and 18 at the Centre for work with children at Sofia-City Municipality, who stay episodically or every day in the street, alone or accompanied by an adult or in an informal group, who live or work in the street (uncontrolled, begging, pickpockets, becoming prostitutes). Out of 166 children who used the service for 2009, 2 (11-year-old boys) used inhalants (glue).

The Crisis centre established at Sofia-City Municipality for children who have suffered from violence within or outside the family provides a social service of a resident type for children between 3 and 18, who have experienced physical, psychic, sexual violence or trafficking. Of all the 40 children accommodated in the centre during the second half of 2009, only 1 (a seventeen-year-old girl) used cannabis and psychoactive drugs.

The two centres provide social and psychological support and undertake actions to return the children back to school or to the education system.

Social reintegration

Persons suffering from different kinds of addiction fall within the range of the target groups under several schemes of giving gratuitous financial support under Priority axis 5 of the Operational Programme Human Resources Development 2007-1013:

The Social services for social inclusion Scheme aims at applying new, steady and comprehensive approaches to raising the quality of life of vulnerable groups and at social exclusion prevention and overcoming of its consequences. The scheme includes three components with a focus on social services for children, social services for adults and development of innovative forms of social services that have not been regulated in the Rules for the Application of the Social Assistance Act. A set of social services for overcoming of addictions may be funded within the frames of the third component. The funds envisaged for the whole scheme amount to 23 000,000 euro and all social service providers are eligible to apply for them. The amount of the gratuitous assistance provided may vary between 80 000 to 250 000 BG leva. The expected results include introduction of 50 new services within the community, support for 30 existing services, reintegration in the community of at least 180 persons accommodated in specialised institutions and others.

Housing

To implement programmes and activities for social rehabilitation and reintegration in the community, the Social Assistance Agency keeps a register of Bulgarian natural persons registered under the Commercial Law, legal persons and physical persons carrying out commercial activity, and legal persons that have emerged according to the legislation of another member-country of the European Union or another state form the European Economic Area. There are 4 non-government organisations entered in the Agency’s register, which are eligible to provide the ‘Protected home’ social service for drug addicts. In view of the fact that, according to Art. 47 of the Rules for the application of the Social Assistance Act, registered persons submit to the Agency a report of their activities related to the provision of social services until 31 May every year, at this stage we can’t furnish you with the exact information yet, concerning the ‘Protected home’ service providers who have actually performed the activity for drug addicts, neither can we specify the number of addicts who have been actually served. From the processed information about the activity of the social

service providers entered in the Register, the activity of the following non-government organisations has been reported to date: Mothers against Drugs Association – Plovdiv provides the service ‘Public information centre for persons above 18’; work is being done also on the programmes ‘Drugs in the daylight’ and ‘Meetings with parents’. In 2009 320 persons received services; Betel – Bulgaria Foundation provides the social service ‘Protected home for drug and alcohol addicts’ in the village of Vladimir, region of Radomir, where 22 men have been accommodated and in Sofia, Gorna Banya Quarter, for 8 women. The Foundation works on three programmes: ‘Drugs in the daylight, ‘Meetings with parents’ and ‘Rehabilitation of drug and alcohol addicts’.

At the ‘Open your eyes’ Association – an orthodox centre for providing of spiritual care – there is a protected home functioning as part of the programme for re-socialisation and reintegration of young men with psychoactive substance dependence. In the protected home addicts are assisted in looking for a job. During the first months they have a personal teacher who observes them and helps them solve their personal conflicts, as well as those with society. The participants in the programme are encouraged to continue the education they have already started or acquire a higher educational degree. One of the criteria for the personality rehabilitation is the creation of a new circle of friends. Leaving the protected home is recommended after a stable friendly circle of persons who have not used psychoactive substances has been created. For this reason, there is no time fixed for the addicts’ stay in the programme. They leave the programme after they have created a stable relationship with another person.

Education / training

The target group of unemployed who have successfully undergone a course of treatment for drugs is included within the scope of the National Programme for Employment and Vocational Training of Persons with Permanent Disability. The Programme provides the following possibilities: ~ Motivation training to acquire skills of active behaviour on the labour market and for fulfilment in work; ~ Motivation for acquiring and improvement of key competences; Training to acquire vocational qualification which conforms to the persons’ abilities and to the employers’ needs. Full-time or part-time employment is provided for unemployed persons for not less than 36 months in the jobs created under the programme.

Through its activity the Employment Agency and its territorial units will continue to give the necessary assistance to groups at disadvantage on the labour market, a part of which are people who have successfully passed a course of treatment for drugs.

Employment

In the conditions of an economic crisis the risk of unemployment for persons from disadvantaged groups on the labour market grows. In this situation, the role of the active policy as an instrument for encouraging employment and effective social integration is essential. In view of improving the access to employment for people from disadvantaged groups, the efforts made by the Ministry of Labour and Social Policy, in cooperation with the social partners and nongovernment organisations, are intended for provision of a wider range of services containing vocational guidance, activation, employment intermediation, inclusion in training for acquiring of knowledge and skills in demand on the labour market, subsidisation of employment, etc.

Unemployed persons who have successfully undergone treatment for addiction are a target group under the National Programme for Employment and Vocational Training of Persons with Permanent Disabilities. Selection of these people for work on the programme is made by the Employment Office directorates on the basis of document proving the successful completion of a course of treatment for drugs. The employed persons’ remuneration and social security payments for a maximum period of 36 months are financed with state budget funds. Due to the limited financial resource for active policies on the labour market, this year the employment of persons hired in previous years is subsidised.

On registering as unemployed at the Employment Office directorates the persons are not obliged to provide information about an existing drug problem, even in case of successfully passed treatment. This makes it difficult to identify the persons of this target group and refer them to appropriate training and employment. Very rare are the cases when unemployed people would talk about an existing or an ex- drug problem. This information may be obtained at the Employment Office directorate, when the persons are accompanied by their friends or relatives upon registration. Unemployed drug addicts looking for a job may use all the services under the Employment Encouragement Act, as follows: ~ Information about announced vacancies; ~ Information about programmes and measures for preservation and encouragement of employment; ~ Intermediation for information and employment; ~ Psychological assistance; ~ Vocational guidance; ~ Inclusion in adult training; ~ Inclusion in programmes and measures for employment and training; ~ Scholarship for education, money for transport and accommodation during the time of training.

The Social Entrepreneurship – Popularisation and Support of Social Undertakings (Pilot Phase) scheme with a budget of 15 680 000 BG leva aims to support the development of social entrepreneurship as a possibility of improving the quality of life of persons from risk groups and of overcoming social exclusion. This scheme is to be implemented through a procedure for selection of projects, with the social service providers being admissible beneficiaries, in accordance with the Social Assistance Act and the Rules for its application. As a result of its implementation it is expected to create or develop further 40 models of social undertakings where protected jobs for an average of 5 persons from disadvantaged groups who are not in a position to participate in real labour activity will be provided. In addition, a minimum of 40 social service providers are expected to be trained and a minimum of 40 information campaigns to attract the civil society and raise social awareness about the possibilities of social entrepreneurship.

In addition to the New Possibilities scheme with a budget of 30 million BG leva, the municipalities will have the opportunity to receive up to 300 000 leva for creation of new social undertakings such as public laundries, soup kitchens, planting and public service development enterprises, as well as ones that ensure the municipal administration’s technical support for the activity. It is expected that permanent employment of at least 800 persons from the most disadvantaged groups, including persons with disabilities, single mothers, persons who have left penitentiary institutions, persons suffering from different addictions, etc. should be provided.

The first in the country Club of patients with alcohol and drug addiction and their families has been set up at the State Psychiatric Hospital for Treatment of Drug and Alcohol

Addictions, following the method of Prof. Vladimir Hudolin 81 . All clubs created by this method are an effective way of successful restoration of social functioning during the time of social reintegration. They are forms of long-term support in the time of resocialisation and their aim is to improve relationships in the family, change the social environment, maintain abstention, get their jobs back or find a new one. The activities of the club at the State Psychiatric Hospital for Treatment of Drug and Alcohol Addictions are based on the idea of the socio-ecological approach for changing the dependent way of life of the person and family and for building a new lifestyle that will lead to their better functioning within the community framework. This can be achieved by finding a new job, finding a new social environment that excludes psychoactive substance use. In 2009, the following periods in the club existence could be marked: • 36 persons looked for the club services • 3 of the club members have got their previous job. • 5 have started a new job • 7 of the families have improved their relationships • The club ensures a new social environment free from alcohol consumption • The club has been visited by an employer once. • 6 of the club members firmly maintain abstention from alcohol consumption • 4 families have dropped out of the club

81 Source: State Psychiatric Hospital for Treatment of Drug and Alcohol Addictions – Suhodol, Sofia

9. Drug-related crime, prevention of drug related crime and prison

Within this section the following basic topics will be examined: Crime associated with drugs; Prevention of crime associated with drugs; Interventions in the criminal justice system; Drug use and problem drug use in prisons; Responses to health consequences associated with drug use in prisons.

In considering the topic of crime associated with drug use in the context of the report cases of criminal and non-criminal offences associated with drug use (use and possession for use), drug supply (for growing, production, trafficking and sale) and other crimes associated with drugs have been addressed. The report includes an overview of police data, data from the National Investigation Service , data on the activities of the Prosecution regarding the implementation of the action plan for reducing demand and supply of drugs , data on cases and persons brought to trial in the courts of the Republic of Bulgaria , data from the National Statistical Institute on crimes associated with drugs and data on antisocial behaviour and crime committed by minors and under-age persons. The presentation of the topic of drug use in prisons is based on routine information directly from the prison administration and targeted survey of prisoners in Bulgaria.

Drug related crime

Crime (arrests/crime reports on trafficking/production/cultivation, etc.) Police Data According to data from the District Police Directorates in 2009 in Bulgaria the total number of detainees with drugs was 3159 1, which confirms the trend from 2006 of an increase in the number of arrested persons (see Table 9-1). The Bulgarian nationals detained with drugs were 3134. Of these, 2,891 were men and 243 were women.

Table 9-1 NUMBER OF PERSONS DETAINED WITH DRUGS Year 2006 2007 2008 2009 Total number 2524 2699 2847 3159 Bulgarian nationals 2498 2678 2816 3134 Foreign nationals 26 21 31 25 Source: Ministry of the Interior

The number of persons distributing drugs in 2009 was 850 (compared to 813 in 2008) or 21% of the total number of registered persons (users and distributors). 94 (or 11.1%) of

1 Report on the work of the District Police Directorates along drugs lines for the period 01.01.2009 - 31.12.2009.

the distributors were minors and under-age persons. 385 (45.3%) distributed cannabis, 206 (24.2%) - heroin, 32 (3.8%) - cocaine and 227 - synthetic drugs - Ecstasy, amphetamines, barbiturates (26.7%). In 2009, the total of 3124 exchanges of letters were filed to initiate preliminary proceedings against persons using and/or distributing drugs. This number increased by over 20% compared to the exchanges of letters in 2007 (2601). In 2009 Sofia Directorate of the Interior filed most of the exchanges of letters in 2009 - 1464, then the Regional Directorates in Plovdiv (194), Varna (49), Blagoevgrad (36) and Ruse (35). Of the total exchanges of letters 2456 were against persons using and distributing drugs, and 668 were against persons distributing drugs. 2 The proportion of “users and distributors/distributors only” in the period 2006-2009 was moving within the ratio 4:1 (see Table 9-2). Table 9-2 NUMBER OF EXCHANGES OF LETTERS FILED TO INITIATE PRELIMINARY PROCEEDINGS Year 2006 2007 2008 2009 Against persons using and distributing drugs 1892 1965 2098 2456 Against persons distributing drugs 505 426 503 668 Total number of exchanges of letters 2397 2391 2601 3124 Source: Ministry of the Interior

Investigation Data According to data from the National and Regional Investigation Services the total number of investigated preliminary proceedings for smuggling and drug trafficking in 2009 was 102 (see Table 9-3). 66 of these were closed, 19 were referred to the court. The accused persons were 29 and all of them were adult Bulgarian nationals. 2 persons were remanded in custody. During the last 4 years a downward trend have been observed in the investigated preliminary proceedings (from 947 in 2006 to 102 in 2009), closed proceedings and accused persons in them.

Table 9-3 INVESTIGATIVE CASES IN THE NATIONAL AND DISTRICT INVESTIGATION SERVICES FOR DRUG SMUGGLING AND TRAFFICKING (2007-2009) (in absolute numbers) 2007 2008 2009 1. Total number of investigated preliminary proceedings 500 171 102 2. Total number of closed cases 421 132 66 Including referrals to the court 52 19 3. Accused persons 206 88 29 Of these: - remanded in custody 7 6 2 - foreign nationals 0 3 0 - minors (only Bulgarian nationals) 5 3 0 - adult Bulgarian nationals 201 82 29 Source: National Investigation Service

2 Report on the work of the Police Directorates along drugs lines for the period 01.01.2009 - 31.12.2009.

Prosecution Data In 2009, for drug and precursor crimes (against public health and trafficking/customs smuggling of drugs), the total of 5291 pre-trial proceedings (PTP) were observed compared to 4332 pre-trial proceedings in 2008 and 4609 in 2007 3. In the period 2006- 2008 a trend of decreasing the number of cases of such crimes was observed. In 2009 an increase in the number of observed PTP of over 22% compared to that of 2008 was reported (see Table 9-4)

Table 9-4

MAIN INDICATORS IN THE PROSECUTORIAL ACTIVITIES IN CONNECTION WITH CRIMES ASSOCIATED WITH DRUGS AND PRECURSORS (2007-2009)

(in absolute numbers) 2007 2008 2009 Observed PTP 4609 4332 5291 Initiated PTP 3438 2999 3671 Closed PTP 3066 3126 3827 Prosecutorial acts submitted to court 1869 1690 2028 Brought to justice persons 2142 1926 2227 Convicted persons 1463 1576 1816 Persons convicted by a final verdict 1393 1403 1605 Acquitted persons 121 70 64 Acquitted persons with an effective sentence 63 19 23 Source: Supreme Prosecutor’s Office of Cassation

Drug-related crime was investigated as a priority - speedily, qualitatively and efficiently. 53% of closed cases were referred to the court with prosecutor's acts; 72% was the share of persons convicted in relation to persons brought to justice. Law enforcement authorities intensified their efforts to arrest offenders and prove drug-related crime committed by organized criminal groups, rather than consumers and retail distributors of drugs. Crimes related to drug smuggling were also investigated speedily and effectively. 4 For generally dangerous crimes under Articles 354(a), 354(b) and 354(c) of the Criminal Code (CC) - illicit trafficking in drugs and precursors (illegal production, possession, distribution), 5125 (4194 and 4431) PTP were observed. Newly established for the period were 3574 PTP. The biggest number of observed PTP was related to Article 354(a) of the Criminal Code - 4866, of which: • production/processing - 11; • acquiring, keeping, incl. storing - 96; • distribution - 434; • large amount - 73; • very large amount - 5; • acquiring/keeping for distribution in public places - 74;

3 Report on law enforcement and on the activities of the Prosecution and the investigative bodies in 2009 4 Ibid.

• ordered by or pursuant to an organized crime group - 10; • acquiring/keeping - 3033; • minor cases - 1129.

3690 PTP were closed. 1297 PTP remained in procedure within the investigating authorities. The prosecutors determined 3736 PTP. 1997 prosecution acts against 2179 accused persons, including 20 foreign nationals, were brought to court. 366 PTP were solved by cessation orders. 1262 PTP were abandoned. The persons convicted at year-end were 1764 and in respect of 1542 of them sentences were executed. 63 accused persons were acquitted and in respect of 22 persons the verdict of “not guilty” was executed. For offences against the customs regime - crimes under Article 242, paragraphs (2) through (4) and paragraph (9) of the Criminal Code 166 (138 and 178) lawsuits were observed. 97 proceedings were newly instituted. Closed were 98 pre-trial proceedings. At the end of the period – 62 PTP remained in procedure within the investigating authorities. The prosecutors determined 91 PTP. 31 prosecution acts were submitted to court. Accused in them were 48 persons, of which 16 foreign nationals. 24 PTP were abandoned and 36 were terminated. The persons convicted at the end of the period were 52. Against 63 persons sentences were executed. 1 person was acquitted. The territorial distribution and movement of this category of lawsuits in appellate districts in 2009 showed that most lawsuits that had a subject of drugs were observed in the jurisdiction of Sofia Appellate Prosecutor's Office (AP) . The total number of pre-trial proceedings in Sofia AP was 2011, compared to 2544 in 2008 (see Table 9-5). 937 (778 in 2008) were referred to court, 563 persons were convicted (574 in 2008), and 17 persons were acquitted. Next is the jurisdiction of Plovdiv Appellate Prosecutor's Office . Data shows that the total observed cases were 708 in 2009, and 724 in 2008. There was an increase in the prosecution acts submitted to court – 496 in 2009 and 444 in 2008. The number of persons convicted during the year was the same as in 2008 - 530. There was one acquitted person. In the jurisdiction of Varna Appellate Prosecutor's Office a total of 334 lawsuits were observed, compared to 448 pre-trial proceedings in 2008. The cases referred to court were 196, compared to 148 in 2008. Convicted by the first instance court were 161 persons (155 persons in 2008), and again only one person was acquitted.

Table 9-5 TERRITORIAL DISTRIBUTION AND MOVEMENT OF CRIME-RELATED LAWSUITS ASSOCIATED WITH DRUGS AND PRECURSORS BY APPELLATE JURISDICTION (2009)

(in absolute numbers) Prosecution Appellate Newly initiated Convicted Acquitted acts submitted jurisdictions PTP persons persons to court Sofia AP 2011 937 563 17 Plovdiv AP 708 496 530 1 Varna AP 334 196 161 1 V. Tarnovo AP 306 223 161 3 Burgas AP 303 168 182 1 Military AP 9 8 8 0 Source: Supreme Prosecutor’s Office of Cassation

In the jurisdiction of Veliko Tarnovo AP, the total number of observed lawsuits for such crimes was 306 (289 2008). 223 prosecutorial acts were submitted; the number of convicted persons was 161 (124 in 2008). 3 persons were acquitted. In the jurisdiction of Burgas AP the total number of observed lawsuits was 303, compared to 315 pre-trial proceedings in 2008. There was a slight increase in the cases referred to court which were 168 compared to 162 in 2008. The number of persons convicted in 2009 (182 persons) was approximately equal to that in 2008 (181 persons). One person was acquitted. The lowest share (understandably, in view of the limited range of subjects of crime) is that of the proceedings conducted by the Military Prosecutor's Offices of Appeal: 9 pre-trial proceedings were observed and 8 persons were sentenced.

Data on lawsuits and persons brought to trial in the courts of the Republic of Bulgaria According to information from the Supreme Judicial Council in all courts in Bulgaria lawsuits are conducted and persons are sentenced on the basis of the relevant texts of the Criminal Code (CC) - Article 242 and Articles 354(a) through 354(c). These are the texts of criminal drug trafficking (Article 242), the acquisition, production, processing, storage, distribution of narcotic substances or their analogues, and inducing or assisting another person to use narcotic substances or their analogues (Article 354(a)-354(c)). Information on the activities of courts of first instance in the country shows that in 2009 district, regional and military courts had to hear a total of 1930 lawsuits related to drugs (see Table 9-6). Of these, 483 ended with a sentence and the total number of convicted persons was 1594. The total of 1046 lawsuits were abandoned and 238 were appealed against. Most often imprisonment of up to 3 years was imposed. The total number of imprisoned persons in this type of punishment was 1040, conditional sentences being 646 of them. Agreements to solve matters, approved by the court in 2009 (under Articles 381-384 of the Criminal Procedure Code), were 958 and persons with inflicted punishment were 997.

Table 9-6 INFORMATION ON LAWSUITS AND BROUGHT TO TRIAL PERSONS IN THE DISTRICT (CITY), REGIONAL AND MILITARY FIRST INSTANCE COURTS IN 2009 (in absolute numbers) COURTS DISTRICT REGIONAL MILITAR TOTAL (CITY) Y Crimes, associated with narcotic substances (Articles 354, 354( а), 354(b), 354(c) of the CC) INFORMATION ON LAWSUITS Matters remained undone in the beginning of the 85 274 2 361 reported period Submitted lawsuits - total 353 1211 5 1569 including newly instituted ones 5 1145 4 1154 Lawsuits for hearing 438 1485 7 1930 Total closed cases 376 1147 6 1529 Solved essentially by sentence 128 353 2 483 Abandoned - total 248 794 4 1046 including agreements executed under 221 733 4 958 Articles 381-384 Matters remained undone at the end of the 62 338 1 401 reported period Closed cases within 3 months 290 784 6 1080 Cases appealed against 97 141 0 238

INFORMATION ON BROUGHT TO TRIAL PERSONS Brought to trial persons - Total 469 1075 6 1550 Including acquitted persons 14 62 1 77 Convicted persons - Total 438 1151 5 1594 Including under-age persons 8 47 0 55 Punishments imposed Imprisonment of up to 3 years Total 348 688 4 1040 Probationary sentence 179 463 4 646 Imprisonment from 3 to 15 years 60 8 0 68 Fine 0 364 0 364 Probation 0 52 0 52 Other punishments 25 44 1 70 Persons punished under Articles 381-384 263 730 4 997 Source: Supreme Judicial Council

Lawsuits of crimes associated with trafficking of narcotic substances and precursors thereto (under Article 242) are heard in the District courts. Information on their activities in the country shows that in 2009 District courts were to hear the total of 26 lawsuits associated with smuggling of drugs (see Table 9-7). 4 of them have ended with a conviction, the total number of convicted persons being 18. A total of 17 cases were abandoned and 4 were appealed against. Most often imprisonment of up to 3 years was imposed. The total number of imprisoned persons in this type of punishment was 11, and 10 of them had probationary sentences.

Table 9-7 INFORMATION ON LAWSUITS AND BROUGHT TO TRIAL PERSONS IN THE DISTRICT COURTS FOR CRIME ASSOCIATED WITH DRUG TRAFFICKING IN 2009 (in absolute numbers) INFORMATION ON LAWSUITS Matters remained undone in the beginning of the reported period 4 Submitted lawsuits - total 22 Lawsuits for hearing 26 Total closed cases 21 Solved essentially by sentence 4 Abandoned and closed by agreement 17 including agreements executed under Articles 381-384 13 Matters remained undone at the end of the reported period 5 Closed cases within 3 months 18 Cases appealed against and protested 4 Executed sentences 9 INFORMATION ON BROUGHT TO TRIAL PERSONS Brought to trial persons - Total 20 Including acquitted persons 2 Convicted persons - Total 18 Including under-age persons 0 Punishments imposed Imprisonment of up to 3 years Total 11 Probationary sentence 10 Imprisonment from 3 to10 years 4 Imprisonment from 10 to 30 years 1 Other punishments 2 Persons punished under Articles 381-384 of the Criminal Procedure Code 14 Source: Supreme Judicial Council

The agreements to solve matters approved by the court in 2009 (under Articles 381-384 of the Criminal Procedure Code) were 13 and persons punished were 14. According to data from the National Statistical Institute (NSI) the total number of drug- related crimes (under Article 354(a)-354(c)) in 2009 was 1372 5. Of these, 722 ended with a conviction (622 – with probationary sentences), 33 - with acquittals, 9 were abandoned, and 1 with an exemption from punishment. Persons convicted for drug-related crimes were 1297 (of these, 93 women). 1228 persons were convicted for one crime, 65 for two crimes and 4 for three or more crimes. In 2009, drug-related crimes that ended with a conviction were 1329, which is an increase of more than 42% compared to 2008 when they were 933. Similar is the increase of persons convicted for drug-related crimes – there was an increase of nearly 37% compared to the previous year. 6 (See Table 9-8)

Table 9-8

DRUG-RELATED CRIMES THAT ENDED WITH A CONVICTION AND CONVICTED PERSONS 2008-2009

(in absolute numbers) 2008 2009 Article 242(2) Article 354( а) Article 242(2) Article 354( а) and (3) – 354(c) and (3) – 354(c) Crimes 19 933 24 1329 Convicted persons 21 949 25 1297

Source: National Statistical Institute

If the distribution of persons convicted for drug-related crimes in 2009 by regions of the country is examined, the NSI data show that most convicted persons (489) were in the Southwest region, which is explained by the presence of regional centres such as Sofia (260 persons) and Blagoevgrad (147 persons) 7. Plovdiv region ranks second in persons convicted for drug-related crimes (192). In the Northwest region most convicted persons were in Pleven - 93. (See Table 9-9) As regards minors and under-age persons, perpetrators of drug-related crimes, again the highest number reported was in the Southwest region (100), only in Sofia-city they were 93. Nearly equal numbers were observed in the Southeast region (24), South Central region (22) and Northeast region (19).

5 Source: http://www.nsi.bg/otrasal.php?otr=25&a1=839&a2=840&a3=841&a4=843#cont 6 Data are collected through comprehensive monitoring by means of a statistical form “Card for accused person (1-CC)”, filled by the bodies of pre-trial and court proceedings. 7 Source: http://www.nsi.bg/otrasal.php?otr=25&a1=839&a2=883&a3=928#cont

Table 9-9

CONVICTED PERSONS, MINORS AND UNDER-AGE PERSONS, PERPETRATORS OF DRUG-RELATED CRIMES BY STATISTICAL REGIONS AND DISTRICTS IN 2009

(in absolute numbers) Statistical regions and Convicted Minors and under-age persons, perpetrators of drug- districts persons related crimes Total incl. 8-13 years of 14-17 years of women age age Total incl. Total incl. women women Total for the country 1297 180 30 6 - 174 30 Northwest region 151 9 - 4 - 5 - Vidin 6 1 - - - 1 - Vratsa 18 4 - 3 - 1 - Lovech 11 ------Montana 23 1 - - - 1 - Pleven 93 3 - 1 - 2 - North Central Region 109 6 1 - - 6 1 eliko Tarnovo 32 2 1 - - 2 1 Gabrovo 19 3 - - - 3 - Razgrad 7 ------Ruse 24 ------Silistra 27 1 - - - 1 - Northeast region 71 19 3 - - 19 3 Varna 45 14 3 - - 14 3 Dobrich 17 5 - - - 5 - Targovishte 1 ------Shumen 8 ------Southeast region 155 24 1 - - 24 1 Burgas 55 14 1 - - 14 1 Sliven 31 2 - - - 2 - Stara Zagora 54 8 - - - 8 - Yambol 15 ------Southwest region 489 100 19 2 - 98 19 Blagoevgrad 147 ------Kyustendil 33 3 1 - - 3 1 Pernik 38 1 - - - 1 - Sofia 11 3 1 - - 3 1 Sofia - Capital 260 93 17 2 - 91 17 South Central Region 322 22 6 - - 22 6 Kardjali 21 1 - - - 1 - Pazardjik 39 1 - - - 1 - Plovdiv 192 11 3 - - 11 3 Smolyan 3 ------Haskovo 67 9 3 - - 9 3

Source: National Statistical Institute

In 2009, the number of children who passed through Children pedagogical rooms (CPR) for committed by them anti-social acts was 8265 (7952 in 2008, or nearly 4% more) 8. Of these, minors (from 8 to13 years of age) were 2198, and under-age persons (from 14 to 17 years of age) were 6067. For about 497 children (107 of them were girls), the reason for passing through Children pedagogical rooms was alcohol, and for 307 (63 girls) - drug use – a number nearly equal to that of 2008 (314). The number of child offenders in 2009 was 6152 (6043 in 2008, or an increase of nearly 2%). Of these, minors were 1345 and under-age persons were 4807 (see Table 9-10 ). Under the drug-related crime indicator, the National Statistical Institute reported acts committed by 180 children (of these, 30 girls), which maintains the trend from 2003 to reduce child perpetrators of drug-related crime. 9

Table 9-10

MINORS AND UNDER-AGE PERSONS, PERPETRATORS OF ANTI-SOCIAL ACTS AND DRUG-RELATED CRIMES (2002-2009) (in absolute numbers)

2002 2003 2004 2005 2006 2007 2008 2009

Children who passed through CPR for committed by them anti-social acts Total for the country 11 070 13 196 13 343 12 407 10 765 9 651 7 952 8 265 including: Abuse of alcohol 554 612 721 802 652 471 401 497 Use of narcotic 846 841 920 584 473 492 314 307 substances Child offenders

Total for the country 8 662 8 653 9 607 10 146 9 720 8 541 8 541 6 043 including: Drug-related crimes 394 385 379 252 232 203 180

Source: National Statistical Institute

Other crimes (e.g. crime against property, illegal prostitution, illegal prescriptions, violence under the influence of drugs, driving, etc.)

No current information is available for other crimes associated with drugs.

Interventions in the criminal justice system

An alternative to imprisonment in the Republic of Bulgaria is probation . According to Article 42(a) of the Criminal Code, probation is a totality of measures for control and impact without imprisonment, which are imposed together or separately . These measures include:

8 Source: Anti-social acts and offences of minors and under-age persons http://www.nsi.bg/otrasal.php?otr=25&a1=931&a2=932&a3=934#cont 9 Data are collected through comprehensive monitoring by means of a statistical form “Report on the activities of local committees to combat anti-social acts of minors and under-age persons”.

• Obligatory registration at the present address; • Obligatory periodical meetings with a probation employee; • Inclusion in courses for professional qualification and/or programmes for public influence; • Ban to visit the places, regions and institutions indicated in the sentence; • Gratuitous work in favour of the society; • Correctional labour;

In 2010, it is foreseen to develop a programme for individual work with persons sentenced to probation, suffering from drug addiction, which is targeted to promote their inclusion in various interventions, in support of changing the old mindset and attitude towards problems and their solution, acquiring new skills to avoid drug use and crime commission, increasing their motivation for change, awareness of their problem and understanding the consequences of their own behaviour.

Drug use and problem drug use in prisons

According to a database maintained in the General Directorate for Execution of Sentences in 2009 in the places of imprisonment a total of 1038 persons (in 2008 their number was 1542, in 2007 - 1143) were registered as addicts or with problem use of psychoactive drugs . Traditionally, all newly imprisoned persons have access to the health status assessment procedures, diagnostics of needs, assessment of repetition risk and harm and involvement in adaptation-oriented group work.

Responses to health consequences associated with drug use in prisons

In the recent years, in the places of imprisonment an increase in the number of incoming prisoners with drug addiction has been registered. This necessitates that the General Directorate for Execution of Sentences and respectively the managements of the places of imprisonment take measures aimed at: • conducting additional training of the staff to handle that category of prisoners; • curbing withdrawal symptoms of incoming drug addicted prisoners, and subsequent treatment in the process of serving the punishment; • preventing attempts to distribute drugs in penitentiary establishments. In 2009, training courses and seminars were held in cooperation with various non- governmental organisations and government institutions. On the basis of partnership relations in some places of imprisonment health and education programmes were carried out; they were organized and implemented by "Mothers against Drugs" and "Initiative for Health" NGOs. Locally, partnerships with local centres for drug addiction and psychiatric wards expanded, thanks to which the persons involved in methadone programmes continued their treatment after admission to prison or custody. In 2009, continuing methadone treatment in places of imprisonment was provided to about 30 prisoners. Since it is not mandatory, a competent medical staff made an on site assessment of its implementation.

During this period, incoming prisoners with withdrawal symptoms immediately received medical care and subsequent psychiatric and psychological counselling to overcome the symptoms. In the medical centres and in the hospitals in the places of imprisonment about 5 persons passed through the process of detoxification on a monthly basis. At the discretion of the medical centres established in the places of imprisonment, persons with drug addiction were also sent to specialized treatment in the psychiatric ward in the prison of the town of Lovech, and in 2009 53 prisoners passed through it. In all prisons and bigger arrests (Sofia, Plovdiv, Varna) two programmes for working with drug-addicted offenders were implemented. Based on their duration the programmes were divided into two types: • A short-term intensive programme, taking place every day for a month. It included prisoners with drug addiction, who were to serve their sentence, and detainees in the aforementioned arrests. • A medium-term programme, which was implemented for five months and included prisoners with a longer remainder of the sentence imposed. The goal of both programmes was aimed at minimizing the harm of drug use.

The content of the programmes is aimed at developing specific skills and knowledge to identify high-risk situations that trigger drug use, and thereafter to build strategies for dealing with these situations. Furthermore, they present patterns of behaviour, which seek to reduce risks of using psychoactive substances, both for the addicted person and for those around him/her, and for the society. At the end of 2009 under the twinning project BG2007/IB/JH/12 - "Strengthening the role of the prison system”, training of staff from the investigation arrests in Varna, Plovdiv and Sofia was carried out, to implement a short-term programme for minimizing the harm of drug abuse. The actual implementation was expected to start in early 2010. At present, due to the lack of financial resources it is not possible to conduct the training of the programme implementation teams in the investigation arrests in Burgas and Ruse.

Since the beginning of 2009 the programmes have been implemented by prison as follows: • Pleven Prison - two short-term and one medium-term programmes with 12 prisoners in each or the total of 36. • Stara Zagora Prison - one short-term programme with 8 graduates. • Pazardzhik Prison - two short-term programmes with 21 graduates. • Lovech Prison - two short-term programmes with 23 graduates. • Varna Prison - three short-term programmes and two medium-term programmes with 40 graduates. • Plovdiv Prison - one medium-term programme and one short-term programme with 18 graduates; in addition, in Plovdiv Prison six programmes with drug dependent prisoners were conducted with the assistance of the Mothers against drugs Foundation and 57 persons passed through the programme. • Burgas Prison – no programmes were implemented in 2009 as training of staff was made at the end of the year.

• Belene prison - one short-term programme with 8 graduates. • Sliven Prison - two short-term programmes with 18 graduates. • Bobov Dol Prison - two short-term programmes with 24 graduates. • Sofia Prison - two short-term programmes with 24 graduates. In Sofia Prison together with “Initiative for Health” NGO a health and education programme was implemented five times with 15 convicted persons each time or a total of 75 prisoners. Each of them was tested for AIDS and Hepatitis. • Vratza Prison - two short-term programmes with 21 graduates. It is evident from the above information that 352 prisoners with drug dependence have passed through specialized group programmes, or nearly 30% of their total number. In the process of serving the sentence, inspectors in charge of social work and educational work carry out individual correction work with this category of convicted persons, and at any time such persons can receive specialized psychological help. In all prisons mass cultural and sports activities are conducted as one of the objectives of these activities is aimed to limit further criminal and sub-cultural influence. These general penitentiary activities include prisoners with drug dependence. Their participation in sports activities is a concomitant part of the process of detoxification. In view of limiting the spread of drugs in prisons and investigation arrests, it is again planned to purchase and place scanners for baggage screening, but due to lack of financial resources, they have not been put in place yet. Therefore, limiting the spread of drugs in places of imprisonment is a task of the supervisory and security staff. It is only their experience and professionalism that can contribute to the prevention of attempts for taking drugs into prisons and investigation arrests. In order to promote their skills, each attempt is documented by photographs, which are made available to the staff as a practice of taking drugs into prisons. According to the information obtained by the General Directorate for Execution of Sentences, 34 attempts for taking drugs into prisons were registered in 2009. - Heroin - 124 doses - Cocaine - 12 doses - Cannabis - 14 sachets - Amphetamines - 167 tablets - Cigarettes marijuana - 23 pieces For each identified case the operative group in duty of the respective subdivision of the Ministry of the Interior is informed and the substances are seized for analysis. Pre-trial proceedings are initiated. When drugs are detected the prevailing substances are usually heroin, amphetamine and cannabis, and in rare cases - cocaine. No specific information can be given on the quantities found, as the operative groups in duty, which work on the cases, will seize the substances. It should be noted that one of the strategic objectives, namely the implementation of a 12- step programme for working with drug users, was not fulfilled. In two of the prisons it was launched as a pilot programme, but after analysis, its implementation was suspended due to a real failure to provide the necessary resources. In this particular case it was a failure to provide a team to work only on this programme, and to accommodate the participants in the programme in separate dormitories for a long period of time.

As a consequence a medium-term programme for working with drug dependent prisoners was developed, which is applicable in the places of imprisonment and its efficiency is higher. At present, the leadership of the General Directorate for Execution of Sentences continues its cooperation with the National Focal Centre for Addictions and various non- governmental organisations for the purpose of developing and implementing mechanisms for more accurate statistics of drug addicts in the places of imprisonment and programmes for working with such a category of people.

10. Drug markets

Within the framework of this section the following main topics will be considered: Availability and supply; Drug seizures; Price and purity of drugs at street level.

On considering the topic of the availability of drugs and the means of supply attention has been focused on the information and data related to drug availability among the general population and among students and prisoners as specific social groups as well as data related to the manufacture, sources of supply and the models of trafficking in the country and abroad , and different settled routes and ways of production are pointed – in general and by type of substance. On presenting these issues information has been used from the General Directorate “Counteraction to Organized Crime” (GDCOC), “Border Police” at the Ministry of Interior and “Customs” Agency at the Ministry of Finance.

The quantity and number of seizures is the emphasis when analyzing the second topic in the section and attention has been brought on the general trend as well as on the data by types of substances and in some cases - by institutions. Information has been used mainly from the Ministry of Interior and from the “Customs” Agency at the Ministry of Finance.

In this report the topic of price and purity of drugs at street level is presented using information concerning the price at street level (on data from two sources- police and the local regional institutions), as well as the purity of drugs at street level and the composition of drugs/tablets – by type of drugs . When presenting these issues information and analyses have been used from General Directorate “Counteraction to Organized Crime” (GDCOC), from the Regional Councils on Drugs from Forensic Science Institute (FSI) and from 2010 Statistical Bulletin of European Monitoring Centre for Drugs and Drug Addictions (EMCDDA).

Availability and supply

Perceived availability of drugs, supply, access to drugs

There is no new current data on supply and access to drugs among the general population, specific groups/locations/settings.

Drugs origin: national production versus importing

82 Source: “Drugs and Terrorism”, Kitan Kitanov, PhD

1993–2001, namely during and right after the wars in Yugoslavia in order hostilities and seizures to be avoided. During this period on the average of 86,9% of Afganistan heroin and morphine was trafficked through the route. The Western Balkan countries (Bosnia and Herzegovina, Croatia, Macedonia, Serbia и Monte Negro, Kosovo) are transit parts of the Balkan heroin road. Especially topical is the route from Afganistan and Turkey through Bulgaria– Macedonia – Kosovo – Albania – Italy. On tracing the manufacture of synthetic drugs in Bulgaria, usually it is a matter of small laboratories in private residences. The production stages in the synthetic drugs manufacturing are territorially separated in order not to be detected easily. Small quantities are manufactured answering the demands of for the local market mainly. 83

Trafficking patterns inside and outside the country

Decentralization in the cocaine trafficking from countries in South America to Europe and Bulgaria was observed in 2009 with the active participation of Bulgarian citizens, used for couriers.84 It is typical that both heroin and cocaine were trafficked using the same couriers. The share of the seized heroin trafficked to the EU countries in small quantities has increased– Bulgarian citizens in their personal luggage. A trend was noticed for changing the used routes by the organized crime – as starting points for the departure of the couriers countries of the EU were used, for instance Greece, Romania and Bulgaria. Bulgaria is mainly a transit country for the heroin, trafficked via cargo vehicles or cars. In some cases the drug is re-loaded in Bulgaria and the cargo vehicle continues along its route without the drug. The bus transport was actively used by drug groups, lead by Nigerians and active on the territory of Turkey, Bulgaria and other EU countries.85 In double walls in suitcases possessed by passengers traveling in buses from Turkey to Bulgaria or Romania or Greece heroin packages between 5 and 8 kilograms are trafficked. After that by plain or other type of transportation directly or transitly the couriers continue traveling to Italy, United Kingdom (UK) etc. Besides Bulgarian citizens, people from Lithuania, Latvia, Denmark have also been hired as couriers. The established cases in United kingdom with the participation of Lithuanians, Latvians and Danes show that they arrive in Turkey with plain and after a short stay of a couple of days leave for Bulgaria and arrive here by regular buses. From Sofia by Easyjet flights they continue the trip to UK. The collaboration in the heroin trafficking among the Albanian crime groups in the countries along the Balkan road (Macedonia, Serbia, Bulgaria) is a stable trend. The organizational character of the drug distribution is typical for this type of crime activity. It founds expression in specific mechanisms for marketing, contact making only with familiar people, using prearranged expressions and avoiding telephone deals. An increasing trend has been observed in amphetamine, ecstasy and marijuana consumption along with a decrease in the age of the consumers and dealers – people at the age of 12-13.

Drug seizures

Quantities and numbers of seizures of illicit drugs

As a result of the activities of departments in the Ministry of Interior (MI) in combating trafficking and distribution in 2009 were discovered and seized a total of 581 kg, 6900

83 Source: “Counteraction to Organized Crime” Directorate (COCD)” – Ministry of Internal Affairs 84 Source: “Counteraction to Organized Crime” Directorate (COCD)” - Ministry of Internal Affairs 85 Source: Agency “Customs” – Ministry of Finance

doses, 30 balls, 301 ampoules, 19.5 kg and 40 l other drugs and precursors. 86 As a result of specialized police operations conducted throughout the country have seized a total of 9266 kg dry mass and 615 kg green mass cannabis, 41 kilograms of marijuana, 623 sticks and 0,323 kg of cannabis seeds. ( See Table 10-1).

Table 10-1

QUANTITIES OF DRUGS SEIZED BY THE MI IN 2009 Number of Drug Units Quantity interceptions Heroin kg 285.255 65 Cocaine kg 1.139 20 Marijuana kg 41.106 78 Cannabis - stalks number 623 37 Cannabis- dry mass kg 9266.214 110 Cannabis – green mass kg 614.934 47 Cannabis – seed kg 0.323 Hashish kg 0.340 5 Morphine ampoules 301 2 Amphetamine – kg 46.187 58 substance kg 206.624 Amphetamine – tablets 18 number 265 Ecstasy tablets 6635 12 Phenylacetic acid kg 19.500 1 BMK (P2P) liters 40 1

Source: “Counteraction to Organized Crime” Directorate

In 2009, customs officials prevented 105 cases of illegal narcotics with a total of 1,242.037 kilograms , 2005 tablets and 4 cactus. Observed number of cases has increased by about 28% over the previous year, and seized quantities are similar. 87 Detained offenders from 10 different nationalities, with 84% of them are citizens of countries of Southeastern Europe (Bulgaria, Turkey, Romania, Serbia and Montenegro). There is a slight decline in the share of Bulgarian drug couriers, but for the third consecutive year they have more than 50% of all detainees. Heroin became the most often smuggled drug in 2009 the borders of Bulgaria (see Table 10-2). Bulgarian Customs Administration (BCA) prevented 32 cases of illicit trafficking in heroin with a total of 927,950 kg, which is 75% of all seized drugs. Observed number of cases is comparable to that of the previous two years, but in terms of quantity seized a slight decline of 15% compared with 2008.

86 Draft Report of the “Coordination and Information Analysis “ Directorate– MI Implementation of the Action Plan for National Strategy to Combat Drugs in 2009. 87 Source: Results of the Customs Agency in the field of combating illicit trafficking of narcotic substances and precursors in 2009.

Table 10-2

QUANTITIES OF DRUGS SEIZED BY THE CUSTOMS AGENCY OVER THE PERIOD 2005-2009

Year 2005 2006 2007 2008 2009 Cannabis resin (kg) 0.002 29.792 0.122 0.041 44.167 Cannabis grass (kg) 39.726 6.410 5.313 0.136 5.151 Cannabis plants (stalks) - 400 - - - Heroin (kg) 324.499 492.804 977.421 1090.197 927.950 Cocaine (kg) 131.460 63.333 2.581 3.959 234.111 Opium (kg) - - 53.096 9.281 - Amphetamines (kg) 406.718 281.802 0.001 101.876 0.088 Ecstasy (kg) - 75.126 1.505 55.864 23.074 Ephedrine (kg) - 9.430 183.355 42.904 - Psychotropic substances 30 168 81 385 9 162 1 260 1 978 (tabl.)

Source : Customs Agency

Last year cars are again the most common mode of transport for trafficking heroin (550,557 kilograms in 15 cases), by monitoring the consecutive increase in the average quantity transported in a shipment (2007: 20 kg; 2008: 30 kg, 2009: 37 kg). Eight of seizures hiding places are located in the floor of the car, they are specially constructed or operated structural cavities. It is noteworthy number of seizures (3) where the drug was hidden in secret chambers in the floor a car Citroen Picasso Ksara. Apart from Bulgaria, those cars loaded with drugs in 2009 were captured in Germany (2) and Italy (1). Ported quantities of heroin in this model vary between 20 and 79 kg.

In 2009 the quantity of heroin seized in trucks significantly decreased (2008: 472 kg in 6 cases, 2009: 229 kg in 4 cases).

For the second consecutive year there is increase in the quantities of seized heroin transported by buses traveling on regular lines (2007: 13 kg in 6 cases; 2008: 53 kg in 5 cases; 2009: 95 kg in 10 cases ). In all seizures in buses, the heroin was concealed in transported luggage; the most frequent hiding is a double bottom of a suitcase or travel bag. But the two biggest quantities (24 kg and 46 kg) were transported in bags without special shelter as unaccompanied luggage. In both cases, the participation of the crew of the bus in the traffic was incontestable. The biggest quantities of illicit trafficking heroin in 2009 were disclosed by the custom officers at the Bulgarian-Turkish border - CP Kapitan Andreevo and Malko Turnovo CP, similarly CP Kalotina on the our border with Serbia, where the officers seized the biggest quantity of heroin in last year - 95 kg.

In 2009, there was a sharp drop in the customs seizures of synthetic drugs in the previous year. The only significant case is ascertained on the CP Gyueshevo where customs officers disclosed 23 kilograms of ecstasy concealed in a car with a Netherlands registration, drived by ethnic Turks. In the remaining 9 cases were seized ecstasy tablets and amphetamine for personal use.

Over the last year custom officers at the port of Varna made the first major seizure of cocaine since 2006. In a container arriving from Chile and containing Bolivian wine were found 231.540 kg of cocaine dissolved in the bottles of wine. Interest is the capture of BCP Gyueshevo 2.5 kg of cocaine hidden in the double bottom of the suitcase of a passenger on a bus. The Uruguay courier was landed at the Sofia airport and then continued his journey with regular bus service to Skopje. In 2009 appears the trend found in previous years - the participation of Bulgarian drug couriers in the international cocaine traffick channels from South America to Western Europe (not deliver the drug in Bulgaria). Departments to combat with drug traffic in Central Customs and COCD of Ministry of Interior continue working for international information exchange in several organized crime groups from Nigeria and Bulgarian nationals operating in Bulgaria, who recruited couriers from different regions of the country and provide logistics for their trip.

Over the last years illicit trafficking of cannabis products (marijuana and hashish) in the country's borders did not play a significant role. Mainly the captured quantities are small, trafficked as parcels, mostly from the Netherlands to private persons in Bulgaria. In 2009 on the CP Captain Andreevo the most significant seizure of hashish was made in the last 6 years - 44 kg transported from Turkey to Bulgaria.

Among cases of drug seizures by the Customs Administration 8 more cases were observed of seizured psychotropic substances (0002 kg and 1978 tablets), 6 cases - of hallucinogenic substances (0.256 kg), 3 cases - cactuses peyote (4 pieces), 2 case - leaves coca (3.638 kg) and methadone (3.600 kg).

Traditionally, professional contacts and exchange of information between departments to combat drug trafficking in the Customs Agency and other law enforcement agencies continued in 2009. During joint actions of the Customs Agency, Ministry of Interior and National Security Agency at the country's borders a total of 10 cases were prevented smuggling of narcotic substances, as follows: • in collaboration with the National Security Agency - 72.312 kg of heroin and 231,540 kilograms of cocaine in 3 cases • in collaboration with GDCOC - 28,059 kg of heroin, 2,272 kilograms of marijuana, 0,202 kilograms of hashish, 0,038 kilograms of cocaine in 4 cases • in collaboration with GDGP - 1.043 kg of heroin and 0,023 kg of amphetamine in 3 cases

In 2009 the Customs Agency took part in the international operation "BARTER" to counter the smuggling of heroin and synthetic drugs carried on road transport along the "Balkan route" and its branches, organized at the initiative of SECI Center to fight- Transborder Crime in Bucharest. For the duration of operation customs control was increased at land borders of the country, including intra-EU, resulting in the prevention of 3 attempts for illegal drug trafficking with a total weight of 56.401 kilograms of heroin and 15 ecstasy tablets.

Quantities and numbers of seizured precursors

In 2009 cases of illicit traffic of precursors across the borders of Bulgaria were not established.

Number of illegal laboratories and other production sites dismantled and precise type of illicit drugs manufactured there

In 2009 on the territory of Bulgaria “Department of Drugs” in COCD revealed 3 illicit laboratories for the synthesis of amphetamines and compressible and retained nearly 44 kg of amphetamine substance and more than 202 kg tablets with logo "Kaptagon" destined for markets in the Middle East. Were also detected six greenhouses for growing cannabis.

Price/Purity

Price of the drugs at street level

On the data of the General Directorate “Combating Organized Crime” (GDCOC) in 2009 marked a change only in the price of cocaine, one gram of it was sold for €71.58, €10.23 with less than this maximum price for 2008 (€81.81). Not registered changes in the price of Dutch cannabis – €15.34 per gram during the last two years. In 2009 a package “Petrich” cannabis (3-5 gram) was bought in the price range €7.67-10.23. The prices of other drugs retain the same values as in 2008: heroin – €30.68, аmphetamine – €13-15, еcstasy – €5.11-7.67 per tablet.

The data provided by Regional Drugs Couincils 88 for 2009 indicate a change in the price of all substances compared with 2008. Alteration is mostly in the minimum value of substances as the overall trend is towards a reduction of 1 to 30 Еuro for different psychoactive substances 89 . As for the maximum price values, they remain the same over the last two years for most drugs – cocaine (gram), аmphetamine (gram), еcstasy (tablet). An exception is the maximum price per tablet of amphetamine, which for 2009 is €15.34, €5.11 with less than 2008 (see Та ble 10-3). Last year the minimum price per gram of heroin was €15.34 and the maximum price was €76.69. For the same amount cannabis users have paid a minimum price €0.51 Евро and a maximum price €30.68. In 2009 use of LSD in Bulgaria is regenerated as a dose of the substance was sold in the range of 5.11 to 15.34 Еuro. New to the Bulgarian market is methamphetamine, which has bought for €4.09 minimum price and 30.68 maximum price.

88 The data is provided by 17 Regional Drugs Councils 89 In the comperative analysis does not include the price per gram of heroin and per gram of cannabis, because in 2008 have not been referred by Regional Drugs Councils

Table 10-3

PRICES OF THE MAIN DRUGS (2008 AND 2009) IN ЕURO

Substance Minimum Maximum Minimum Maximum (2008) (2008) (2009) (2009) Cocaine (g) 51.13 81.81 20.45 81.81 Heroin (g) - - 15.34 76.69 Heroin (dose) 1.53 7.67 2.56 10.23 Amphetamine (g) 10.23 30.68 5.11 30.68 Amphetamine (tablet) 2.56 20.45 1.53 15.34 Cannabis (g) - - 0.51 30.68 Marijuana (cigarette) 0.51 5.11 0.51 12.78 Еcstasy (tablet) 3.58 20.45 2.05 20.45 Ме thamphetamine - - 4.09 30.68 (tablet) LSD - - 5.11 15.34 Source: Regional Drugs Councils

General compared with other countries of the European Union prices of essential drugs in Bulgaria are under the overall trend for 2008. Difference exists only in the minimum value per gram of cannabis and per gram of methampethamine and cannabis in Bulgaria in 2009 was sold at the minimum rate of €0.51 (€0.49 a lower minimum value compared with the thrend in Europe), аnd methampethamine to €4.09 (€5.91 less than the general European trend) (see Тable 10-2).

Table 10-4

PRICES OF THE MAIN DRUGS IN BULGARIA AND IN EUROPE PER GRAM IN EURO (2009)

Substance Price in Bulgaria Price in the other European countries 90 Cannabis 0.51-30.68 1-60 Heroin 15.34-76-69 10-264.90 Cocaine 20.45-81.81 5-160 Amphetamine 5.11-30.68 1.5-55.60 Ecstasy 2.05-20.45 0.5-70 LSD 5.11-15.34 1.2-35 Methamphetamine 4.09-30.68 10-148.10

Source: Regional Drugs Councils , EMCDDA

Purity

90 Source: Statistical bulletin 2010, EMCDDA. The aggregate data in the bulletin are for 2008.

In heroin samples no significant change either in number or in content of active component. There is a slight increase in objects than in previous years. Further additivites in heroin are the most and paracetamol, but there are piracetam, benzocaine and phenobarbital. Three-year period 2007-2009 samples, containing cocaine begin to rise slightly and there is a tendency to maintain an average level of purity about 20-25 %. Admixtures in cocaine become more varied: paracetam, benzocaine, procaine, caffeine, lidocaine, tetracaine, phenacetin and levamizol. In 2009 the number of samples containing amphetamine and methamphetamine (powders and tablets) have significantly increased. For comparison, in 2007 the number of amphetamine samples is 571, and in 2008 – 600, while the 2009 г. samples are 804. At the same time reduces the content of active component in objects. Most samles have a purity below 10 %. Regularly occuring admixture in amphetamine is caffeine. In combianation with caffeine from the middle of 2009 г. appears and lidocaine. Other frequent admixtures are: benzocaine, analgin, aspirin, quinine, theophylline, paracetamol, piracetam, metoclopramide, teobromid. Tablets containing MDMA decreased sharply at the expense of those contained amphetamine, and the tablets with chlorophenylpiperazine (CPP) and 2-CB (4-Bromo - 2,5-dimethoxyphenethylamine). Admixtures in them are caffeine, theophylline, quinine, loratidin, paracetamol.

Part B: Selected Issues

11. History, methods and implementation of national treatment guidelines

WHO guidelines coherence: only to be applied to guidelines on methadone treatment for substitution or withdrawal purpose in opioid dependence

Name of Assessors: Tsveta Raycheva MD Yes No Not Applicable specify answer No 1. Choice of treatment 1.2 For the pharmacological treatment of opioid dependence, clinicians □ □ □ □ should offer opioid withdrawal, opioid agonist maintenance and not opioid antagonist (naltrexone) treatment, but most patients should exactly be advised to use opioid agonist maintenance treatment. Do the present guidelines include this recommendation? 1.3 For opioid-dependent patients not commencing opioid agonist □ □ □ □ maintenance treatment, consider antagonist pharmacotherapy using naltrexone following the completion of opioid withdrawal. X Do the present guidelines include this recommendation?

2 Opioid agonist maintenance treatment □ □ □ □ 2.1 For opioid agonist maintenance treatment, most patients should be advised to use methadone in adequate doses in preference to X buprenorphine. Do the present guidelines include this recommendation? 2.2 During methadone induction, the initial daily dose should depend on □ □ □ the level of neuroadaptation; it should generally not be more than 20 X mg, and certainly not more than 30mg. Do the present guidelines include this recommendation? 2.3 On average, methadone maintenance doses should be in the range □ □ □ of 60–120 mg per day. X Do the present guidelines include this recommendation 2.4 Average buprenorphine maintenance doses should be at least 8 mg □ □ □ per day. X Do the present guidelines include this recommendation? 2.5 Methadone and buprenorphine doses should be directly supervised □ □ □ in the early phase of treatment. X Do the present guidelines include this recommendation? 2.6 Take-away doses may be provided for patients when the benefits of □ □ □ reduced frequency of attendance are considered to outweigh the risk X of diversion, subject to regular review. Do the present guidelines include this recommendation? 2.7 Psychosocial support should be offered routinely in association with □ □ □ pharmacological treatment for opioid dependence. X Do the present guidelines include this recommendation?

3 Management of opioid withdrawal

Yes No Not Applicable specify No answer 3.1 For the management of opioid withdrawal, tapered doses of opioid □ □ □ agonists should generally be used, although alpha-2 adrenergic X agonists may also be used. Do the present guidelines include this recommendation? 3.2 Clinicians should not routinely use the combination of opioid □ □ □ antagonists and minimal sedation in the management of opioid withdrawal. X Do the present guidelines include this recommendation? 3.3 Clinicians should not use the combination of opioid antagonists with □ □ □

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heavy sedation in the management of opioid withdrawal. X Do the present guidelines include this recommendation? 3.4 Psychosocial services should be routinely offered in combination with pharmacological treatment of opioid withdrawal. X Do the present guidelines include this recommendation?

4 Pregnancy

4.1 Opioid agonist maintenance treatment should be used for the □ □ □ □ treatment of opioid dependence in pregnancy. X Do the present guidelines include this recommendation? 4.2 Methadone maintenance should be used in pregnancy in preference □ □ □ □ to buprenorphine maintenance for the treatment of opioid dependence; although there is less evidence about the safety of X buprenorphine, it might also be offered. Do the present guidelines include this recommendation?

WHO guidelines coherence: only to be applied to guidelines applied for guidelines on closed settings

In case your guidelines are about closed settings (“closed settings” refers to prisons, work camps, compulsory drug treatment centres and any other institution in which people are detained), state whether they agrees with the “Clinical guidelines for withdrawal management and treatment of drug dependence in closed settings” freely downloadable at: (http://www.who.int/hiv/pub/idu/wpro_withdrawl/en/index.html ).

For each recommendation, please state whether your guidelines include them (even if not with exactly the same wording). Please select only one answer.

Yes No Not Applicable specify answer No 1. Do the present guidelines agree with the “Clinical guidelines for □ □ □ □ withdrawal management and treatment of drug dependence in closed settings ” ?

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Part C: Bibliography

102

Alphabetic list of all bibliographic references used

City Reports of MCNS and PIC in 2007, 2008,2009 Information of the State Agency for Child Protection for 2009 on the Action Plan for the implementation of the National Anti-Drug Strategy 2009 Marinov Ilia, M.D., About prevention – treatment activities related to the abuse of narcotic substances within the MoD in 2009 (Report – analysis of the Head of Mental Health and Prevention Centre) Information on activities in the field held 'addiction prevention’ from ‘Dose of Love’ Association in 2009 Orthodox spiritual center for the care of drug addicts „St. Boian Enravota protomartyr Bulgarian” „CIELA”, Low and information software Report on the implementation of the Action Plan to the National Anti-Drug Strategy in 2008, CIAD - MI, 2010 Reference for the work done by “Police” RD at the “Drugs” Department over the period 01st January 2009 - 31th December 2009 The National Investigation Service Report on the implementation of the law and the activity of the Prosecutors Office and the investigation authorities in 2009 Kitanov Kitan, PHD, Drugs and terorism Report on the implementation of the Action Plan to the National Anti-Drug Strategy in 2009, "Operational and Technical Information" Directorate, Ministry of Interior Results of the Customs Agency in the field of combating illicit trafficking of narcotic substances and precursors in 2009 National Center for Biotechnology Information (NCBI), NIH, MD, USA, Rega HIV Subtyping Tool (version 2.0) – Bioafrica, Katolike Universiteit Annual reports of the rehabilitation and substitution programs in 2008,2009. Report on the patients with drug dependence registered at the Clinic of Toxicology at “Pirogov” MHATEM for 2009 Guidelines for good clinical practice in the substitution treatment, National center for Addictions, Sofia, 2008 Statistical Bulletin 2010, EMCDDA ,The data summarized in the bulletin are for 2008

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Alphabetic list of relevant Internet addresses http://bgpetition.com/dekriminalizaciya/index.html . http://hivdb6.stanford.edu http://hiv-web.lanl.gov http://www.aidsprogram.bg/static_info1.php?main=data http://www.bioafrica.net/virus-genotype/html/subtypinghiv.html http://www.drugsinfo-bg.org/bg/ http://www.ncbi.nih.gov http://www.nsi.bg/otrasal.php?otr=25&a1=839&a2=840&a3=841&a4=843#cont http://www.nsi.bg/otrasal.php?otr=25&a1=839&a2=883&a3=928#cont http://www.nsi.bg/otrasal.php?otr=25&a1=931&a2=932&a3=934#cont www.addicted2life.eu www.antidrugbg.com www.ncn-bg.org www.nsi.bg www.promena.org www.thcfarmer.com

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Annexes

105

List of tables and graphs used in the text

FIGURE 2.1 LIFE TIME PREVALENCE OF NARCOTIC SUBSTANCES AMONG STUDENTS FIGURE 2.2 REASONS FOR FIRST-TIME DRUG USE AMONG STUDENTS FIGURE 2.3 RELATIVE SHARE OF THE STUDENTS ACCEPTING DRUG USE FIGURE 2.4 IS DRUG USE A PROBLEM FOR THE COUNTRY, CITY, SCHOOL FIGURE 3-1 DISTRIBUTION OF THE WISHED FOR AND IMPLEMENTED PREVENTIVE ACTIVITIES ACCORDING TO THE TARGET GROUP FIGURE 3-3 DISTRIBUTION OF THE WISHED INTERVENTIONS PROVIDED, RELATED TO PREVENTIVE ACTIVITIES FIGURE 3-4 ALLOCATION BY TYPE OF PREVENTIVE ACTIVITY FIGURE 4.1 NDIVIDUALS REGISTERED WITH THE “DRUGS” DEPARTMENT (DRUG USERS AND DRUG DEALERS) FIGURE 4-2 NUMBER OF INDIVIDUALS REGISTERED WITH THE FIGURE 5-1 NUMBER OF THE PATIENTS WITH PSYCHIC AND BEHAVIORAL DISORDERS DUE TO USE OF OTHER PSYCHOACTIVE SUBSTANCES (ICD-10, CODE F11-F19) AT THE IN-PATIENT WARDS OF THE PSYCHIATRIC ESTABLISHMENTS IN THE COUNTRY IN THE 1990-2008 PERIOD. FIGURE 6-1 LEVEL OF INFECTION WITH HEPATITIS С VIRUS OVER THE PERIOD 1995-2009

TABLE 10-1 QUANTITIES OF DRUGS SEIZED BY THE MI IN 2009 TABLE 10-2 QUANTITIES OF DRUGS SEIZED BY THE CUSTOMS AGENCY OVER THE PERIOD 2005-2009 TABLE 10-3 PRICES OF THE MAIN DRUGS (2008 AND 2009) IN ЕURO TABLE 10-4 PRICES OF THE MAIN DRUGS IN BULGARIA AND IN EUROPE PER GRAM IN EURO (2009) TABLE 2.1 SURVEYS IN ACCORDANCE WITH THE NFP METHODOLOGY CONDUCTED AMONG STUDENTS IN BULGARIA (2005-2009) TABLE 3-1 NUMBER OF ACTIVITIES ACCORDING TO TYPE OF PREVENTION FOR THE PERIOD 2007-2009 TABLE 3-2 TYPES OF PREVENTIVE INTERVENTIONS TABLE 6- 2 SEROLOGICAL TESTS OF INJECTING DRUG USERS 2009 TABLE 6-1 TOTAL NUMBER OF THE HIV-INFECTED PERSONS REGISTERED SINCE THE BEGINNING OF HIV STATUS TESTING OF BULGARIANS IS PRESENTED TABLE 9-1 NUMBER OF PERSONS DETAINED WITH DRUGS TABLE 9-10 MINORS AND UNDER-AGE PERSONS, PERPETRATORS OF ANTI- SOCIAL ACTS AND DRUG-RELATED CRIMES (2002-2009) TABLE 9-2 NUMBER OF EXCHANGES OF LETTERS

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TABLE 9-3 INVESTIGATIVE CASES IN THE NATIONAL AND DISTRICT INVESTIGATION SERVICES FOR DRUG SMUGGLING AND TRAFFICKING (2007- 2009) TABLE 9-4 MAIN INDICATORS IN THE PROSECUTORIAL ACTIVITIES IN CONNECTION WITH CRIMES ASSOCIATED WITH DRUGS AND PRECURSORS (2007-2009) TABLE 9-5 TERRITORIAL DISTRIBUTION AND MOVEMENT OF CRIME-RELATED LAWSUITS ASSOCIATED WITH DRUGS AND PRECURSORS BY APPELLATE JURISDICTION (2009) TABLE 9-6 INFORMATION ON LAWSUITS AND BROUGHT TO TRIAL PERSONS IN THE DISTRICT (CITY), REGIONAL AND MILITARY FIRST INSTANCE COURTS IN 2009 TABLE 9-7 INFORMATION ON LAWSUITS AND BROUGHT TO TRIAL PERSONS IN THE DISTRICT COURTS FOR CRIME ASSOCIATED WITH DRUG TRAFFICKING IN 2009 TABLE 9-8 DRUG-RELATED CRIMES THAT ENDED WITH A CONVICTION AND CONVICTED PERSONS 2008-2009 TABLE 9-9 CONVICTED PERSONS, MINORS AND UNDER-AGE PERSONS, PERPETRATORS OF DRUG-RELATED CRIMES BY STATISTICAL REGIONS AND DISTRICTS IN 2009

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