TIHOMIR BEZLOV CAS BARENDREGT INJECTING DRUG USERS IN BULGARIA Profile and risks Initiative for Health Foundation Sofia 2004 1 This study was conducted with the joint efforts of Addiction Research Institute IVO - Rotterdam; Initiative for Health Foundation - Sofia; Panacea Foundation - Plovdiv; Doze of Love Association - Bourgas; Pleven 21-st Century Foundation - Pleven. The research team consist of Tihomir Bezlov (senior researcher), Cas Barendregt (senior researcher), Agnes van der Poel (expert), Atanas Rusev (local researcher), Atanas Louizov (local researcher), Dimitar Grancharov, Julian Marinov (local researcher),Mitko Stamatov (local researcher). IVO, Addiction Research Institute Initiative for Health Heemraadssingel 194 Foundation 3021 DM Rotterdam 52A, Todor Kableshkov Str. The Netherlands 1680 Sofia, Bulgaria Phone ++31104253366 Phone/Fax +35929550472 Fax ++31102763988 E-mail [email protected] E-mail [email protected] www.initiativeforhealth.org Panacea Foundation Pleven 21-st Century 19, Bojidar Zdravkov Str. Foundation 4006 Plovdiv, Bulgaria 23, D. Konstantinov Str. Tel/fax: +359 32 626 379 5800 Pleven, Bulgaria e-mail: [email protected] Tel/fax: +3596800271 e-mail: [email protected] Doze of Love Association 17, Graf Ignatief Str. 8000 Bourgas, Bulgaria Phone/ Fax +35956841488 E-mail: [email protected] ISBN 954-91430-5-8 Design: Kostadin Kutrjanov Printing: IFO Design / www.ifodesign.net 2 CONTENTS Introduction 5 Design, methodology and background of the survey 7 1. Demographic and socio-economic profile of the injection drug users 9 1.1. Demographic characteristics 9 1.2. Socio-economic profile 16 1.3. Contacts with public institutions 22 2. Drug use, patterns, sources, mobility with IDU 24 2.1. Patterns of use by psychoactive substances (PAS) 24 2.2. The use of heroin and its alternatives 32 2.3. Starting and length of injection use 33 3. Types of risks with PAS use 36 3.1. Overdose 36 3.2. Places of use 37 3.3. Mobility of IDU 37 3.4. Frequency of injection use 39 3.5. Using shared injecting instruments 43 3.6. Time in prison 46 3.7. Patterns of risky sexual behaviour with IDU 47 4. Evaluation of risks and the place of harm reduction programmes 50 3 4 Introduction With the falling apart of the model of Bulgarian organizations implement harm total police control and the liberalization reduction programmes among the IDU of Bulgaria's economy in the early 90- in the four cities since years 1999 - 2000. ies, heroin becomes commodity easily They implement an outreach approach accessible. This is highly facilitated by to the IDUs providing needles and the country's location on the main road syringes for exchange, as well as health of heroin from Turkey to Western services. As a result from this experi- Europe. Unlike Central European coun- ence the programmes were able to tries such as Hungary, the Czech secure a unique possibility to interview a Republic and Poland, however, Bulgaria great number of not easily approachable has been a much more isolated country persons (from hidden and encapsulated during the time of Soviet domination and communities) who were to provide the heroin epidemic in the middle of the answers to questions that are not easy 90-ies turned into a virtual cultural shock. to talk about. At the same time the country's encapsu- The survey team hopes that after this lation has preserved the conservative survey it will be much more difficult to attitudes of the population, which is make incompetent statements, now that extremely hostile to drug users. As a facts are available. result, the injection drug users in the country's largest cities become hermetic and marginalized groups. Regrettably, despite the epidemic rate of growing use of psychoactive substances after 1990, the public continues to know too little about the drug users, as well as about the risks related to them. The project ,,From Pilot to Professional’’, funded under the EU PHARE programme made possible the conduction of the first national survey among out of treatment injection drug users (IDU) in the country. In the summer of 2003 four Bulgarian non-government organizations - Initiative for Health Foundation - Sofia, Dose of Love Association - Bourgas, Panacea Foundation - Plovdiv, and Pleven 21 Century Foundation in cooperation with the Addiction Research Institute IVO - Rotterdam succeeded in conducting a survey requiring special efforts. The four 5 6 Design, methodology and background of the survey The survey ,,Injecting drug users in in 18 sections, to be covered in 45 min aver- Bulgaria - profile and risks’’ is to meet age length of an interview. several principal aims: The questionnaire was prepared as ! To gain an overall idea of the demo- based on models used on many occasions graphic and socio-economic profile of by the Dutch partners in research projects the country's injecting drug users; of the Addiction Research Institute IVO, ! To attain a clear picture of the immediate Rotterdam. The final version was the out- environment where the drug users live come of a working seminar, attended by (housing, family, frequency of environ- four Bulgarian teams of sociologists - each ment change, etc.); representing one of the Bulgarian non-gov- ! To analyze the existing patterns of drug ernment organizations carrying out the proj- use with regard to the types of psychoac- ect - Initiative for Health Foundation - Sofia, tive substances, frequency of use, man- Dose of Love Association - Bourgas, ner of use, crises during use, etc. Panacea Foundation - Plovdiv, and Pleven ! To analyze the patterns of access to 21 Century Foundation, as well as by drugs; experts of the Dutch partners in the face of ! To describe and analyze the patterns of Cas Barendregt and Agnes van der Poel. risk-posing social behaviour among drug Before the launch of the survey the ques- users; tionnaire was tested in a pilot study of 10 ! To describe and analyze problems faced IDU, and was additionally modified accord- by drug users - difficulties with parents, ingly. law enforcement and access to health A total of 501 IDU were interviewed during care; the interval 28 July - 7 October 2003. ! To explore the main risk factors enhanc- Selection of participants took place in 4 ing the chances for HIV and blood-trans cities according to preliminary quotas deter- mitted infections, along with certain work- mined. 201 interviews took place in Sofia, able alternatives to change the present 100 ones in each Plovdiv and Pleven, and 99 status quo; in Bourgas. The basis for IDU recruitment ! To compare the risk levels among injec- were attendants of the needles and tion drug users (IDU) covered by harm syringes exchange programmes (NEP) of reduction programmes to those with IDU Initiative for Health Foundation in Sofia, of outside of the programmes. To verify the Panacea Foundation in Plovdiv, of Dose of hypothesis that participants on harm Love Association in Bourgas and of Pleven reduction programmes have lower risk 21 century Foundation in Pleven. The quo- behaviour as related to HIV and blood- tas for each of the cities were divided into transmitted infections thanks to having two groups: “participants’’ (“attendants’’) better health care culture and awareness on NEP and “non-participants’’ (“non-atten- of the risks related to injecting and dants’’). Interviewee selection followed the unsafe sex. principle of keeping anonymity, for recruit- As method of collecting information what ing NEP participants their personal anony- was implemented was benchmark interview mous codes were used through which they with respondents (face-to-face). The ques- take part in the programmes. For each of tionnaire contained 261 variables grouped the four programmes a step was chosen to 7 fill the “participants’’ group, observing the it turned out impossible to trace the person principle that must have been NEP atten- behind the respective code, even with the dants for six months before the survey. With close cooperation of the outreach workers. the “non-participants’’ the method used was (2) A large number of the programme atten- "snowball’’ by one step. Each of those dants use false codes (and frequently selected as interviewees gives the names of change them), which renders their identifi- several non-attendants (between 2 and 6) cation impossible. (3) The small number of and the interviewers randomly choose one. stable NEP attendants at the outreach Each respondent was paid 5 BGN for an points was selected for the survey, which interview and 3 BGN for a ,,non-attendant’’ was additionally reduced, especially among they have brought. The initially intended IDU ethnic Roma (a considerable number of proportion between “attendants’’ and “non- attendants were in prison at the time of the attendants’’ was 75% to 25%. survey). (4) The seasonal specificity at the External factors in the process of the sur- time of conducting the interviews - a signifi- vey necessitated certain changes of the cant number of IDU were outside of Sofia at original plan. In Pleven out of 76 regular the time, which largely complicated the attendants six months before the survey 62 process of recruitment of both ,,regular were reached - the rest happened to be out attendants’’, and ,,non-attendants’’. of town for the summer season or due to Supplementary to the benchmark inter- police custody. As a result, the non-atten- view, information was collected in the form dants are 38 instead of 25 planned. In of participant observation. This observation Bourgas the correlation “attendants’’ - “non- involved our staff taking notes about the attendants’’ is 51 to 49, the main reason for interview process, the more relevant events the change being the fact that in the vaca- and issues discussed with IDU, registered tion city the number of non-resident IDU as taking place in their natural environment. seasonally increases times the usual, while This information was taken down in a record the regular attendants scatter around the book to be later analyzed for the purpose of seaside and cannot be reached.