Drug Abuse

4. Problem Drug Use

In the frames of this part, the following basic themes will be examined:
>    Estimation of the prevalence of the problem drug use;
>    The profile of the persons demanding treatment;
>    General characteristics of use from non-treatment sources.

Regarding the estimation of the prevalence of the problem drug use there are no new available data for 2006. However a very brief review is provided, built on results obtained through the Multiplier Method Using Treatment Data and a study using the Capture-recapture method, also experts estimations are used and long term observations. The Multiplier Method Using Treatment Data is used for the national estimation 36, and the Capture-recapture method is used for the local assessment in the capital Sofia 37.

The profile of the persons demanding treatment is based on data from treatment demands regarding the use of narcotic substances in Bulgaria. The data are obtained by the means of monitoring system in which base was the implemented from 1991 until 1998 European project "Multi-city Network on Treatment Demand Data". The project was coordinated from the Pompidou Group to the Council of Europe and more than 20 European cities participated in the project (Stauffacher 1998), including Sofia (from 1994) and Varna (from 1994).

In 2006 the treatment demand monitoring system in Bulgaria covered a total number of 17 inpatient and outpatient units and centers in 6 of the most significant Bulgarian cities (from the viewpoint of the treatment possibilities).

The data regarding the general characteristics and patterns of drug use from non-treatment sources are received from routine source — the information system of the National Police and the Ministry ofinterior 38.

Prevalence Estimates of Problem Drug Use

There are no new available data for 2006.

A brief review of the existing data shows that in Bulgaria the heroin is the substance that is the most strongly connected with the problem drug use (over 90 % of the persons who searched for treatment in the specialized units have indicated it as the primary substance 39).

Based on the available data a general estimation could be made that the number of the problem heroin users in the last few years remains relatively constant and stable, even with slight indications for onset of decrease. Unfortunately, this is not the case for the problem drug users as a whole as long as in the same time indications for increasing the number of the problem amphetamine and "ecstasy" type substances users can be observed 48.

The bigger part of the problem heroin users injecting their drugs. Indications of gradual decrease of used needles and syringes sharing among drug users continue to be observed; this is a good prerequisite for the reduction of health harms due to drug use.

In the spring of 2005 with the leadership of the National Focal Point the collection of primary data from the first of a kind in Bulgaria study — estimation of the problem drug use in Sofia using the "Capture-recapture" method finished. The aim of the study was the formation of the assessment of the number and the profile of the problem drug users (especially heroin) in Sofia. In this way, an estimation of the local prevalence of the problem drug use in the biggest city and the capital of Bulgaria was accomplished.

After using of specific statistical methods and instruments, estimation was formed for 15 748 problem drug users in Sofia. Applying the Confidence Interval of 95%, we can outline a broader range of the estimation - between 9 548 and 26 924 persons. Having in mind that up to December 315' 2004 the total population of the city was 1 221 157 (National Statistical Institute 2005) the estimation for the relative share of the problem drug users in Sofia is 12 / 1000 persons of population. The broad range of this estimation (Cl 95%) is between 7 and 22 to 1000 persons. Referred to the population aged 15-64 y., which to December 315' 2004 was 888 123 persons this estimate could be 17 / 1000 persons of population, with a broad range between 10 and 30 to 1000 persons 41.

By Substance

There are no new available data for 2006.

The total estimation for the number of problem heroin users in Bulgaria is between 20 000 and 30 000. One part of this estimate was obtained through the Multiplier Method Using Treatment Data. This method is based on the size (in absolute numbers) of the sub-group of the problem drug users looking for treatment in a given period of time. This number later is,multiplied by a relevant multiplier reflecting the approximate proportion between the persons searching for treatment and the whole population of problem drug users42.

After applying Capture-recapture method, an estimate was formed for 11 993 problem heroin users in Sofia. Applying the confidence interval of 95%, we can outline a broader range of the estimate — between 9 136 and 15 909 persons. Having in mind that up to December 315' 2004 the total population of the city was 1 221 157 (National Statistical Institute 2005) the estimate for the relevant share of problem heroin users in Sofia is 9 / 1000 persons of population. The broader range of the estimate (Cl 95%) is between 7 and 13 of 1000 persons. Referred to the population aged 15-64 y., which to December 315' 2004 was 888 123 persons, this estimate would be 13 / 1000 persons of population, with a range between 10 and 17 to 1000 persons 43.

Unfortunately, due to different reasons sufficiently reliable and valid estimate for problem users of other opiates, cocaine, and other stimulants is still missing. Anyway according to experts estimates the probable number of problem cocaine users for the whole country is estimated to be around 1 000-2 500, and for those on amphetamines and other stimulants - around 2 000- 3 500 persons ".

By Injecting

There are no new available data for 2006.
After using Capture-recapture method an estimate was formed for 9 686 injecting drug users in Sofia. Applying the Confidence Interval of 95%, we can outline a broader range of the estimation - between 6 642 and 14 461 persons. Having in mind that up to December 315' 2004 the total population of the city was 1 221 157 (National Statistical Institute 2005) the estimation for the relative share of the problem drug users in Sofia is 7 11000 persons of population. The broad range of this estimation (CI 95%) is between Sand 11 to 1000 persons. Referred to the population aged 15-64 y., which to December 31s` 2004 was 888 123 persons this estimate could be 10 / 1000 persons of population, with a broad range between 7 and 16 to 1000 persons 45.

Profile of Clients in Treatment

In 2006 the monitoring system of treatment demand covered 1766 persons, starting therapy in 5 inpatient and 12 outpatient units and centers in 6 of the most significant Bulgarian cities (regarding treatment possibilities) 46. More than 1/4 of the country's population is concentrated there and approximately 4/5 of the residential patients in Bulgaria are there. The data are collected through a form-questionnaire, which is filled in by persons, working with the patients — medical doctors, nurses, psychologists, social workers, observing all the measures for keeping the data confidential. The number of the persons covered is obtained after accomplishing a procedure for identification and elimination of the double counting (double presence of the same person in the whole data set).

Trends in the General Development of Treatment Demand Indicator

In 1994 the system was implemented only in one specialized treatment unit in Sofia (the hospital ward of the National Centre for Addictions); after a little more than ten years later (in 2006) the coverage is significantly wider — specialized units and treatment programmes in six Bulgarian cities, including the three biggest — Sofia, Plovdiv, and Varna — are included (see above). Significantly grew the number of covered treatment demand cases in the period — from 81 in 1994 to over 1300 in the last four years (see Figure 4-1). This growth probably is due as to the increase of drug treatment demand, as to the widening of the coverage of the monitoring system.

years the increase is fluent in the frames of 1300-1800 persons. As though, the reasons however are mostly in the widening of the coverage of the system.

Some of the outlined trends in the treatment demands are:

A The heroin remains the primary problem drug, for which a treatment is searched for;

A The injecting continues to be the most prevalent pattern of drug use among the persons demanding treatment;

A. The treatment demand for the first time ever increased for cannabis and amphetamine users;

A A decrease of treatment demand for the first time for opiates use except heroin is observed.

New Data and Emerging Trends in Treatment Demand

A) Among all starting treatment in 2006

In this analysis all persons who started treatment related to drug use in 2006 (for the first time or ever in their lifetime) are included (they fall in the scope of the monitoring system).

The data from treatment demand in 2006 show some basic features of the group profile of one part of the problem drug users — these ones that looked for treatment. Some of these features are described below, in some cases complemented by emerging trends (see also Table 4-1).

A By the type of the drug

In 2006 98,0 % are with primary problem drug heroin.

Because of a number of reasons and mostly because of the relatively "favourable" ratio effect / price the heroin remains the most widely spread drug among problem drug users.: In every of the last 5 years between 95 % and 98 °A of the persons looking for treatment in relation with a drug problem in the specialized centers have used heroin and/or other opiates.

A. By gender

In 2006 18,4 % of the persons who demanded treatment were women.
In the last decade, the ratio males / females remained always approximately 4:1.

A. By age

In 2006 5,0 % of the persons who demanded treatment were up to 19 years of age, and 87,3 % - up to 29 years of age (total mean age 25,5 years).

>    By age of first use

In 2006 66,3 % of persons who demanded treatment declared that they have started the use of the primary problem drug by the age of 19 y. included, 10,7 % - up to 14 y. included; total mean age when the first use occurred - 18,5 y. (18,7 in 2002).
Therapists warn, and the monitoring system more and more often "detects" patients with heroin problems aged 12-14 years. As a whole, it could be stated that the mean age at first use of the problem drug remains low — for heroin among treatment demands, it is between 18 and 19 years of age, for cannabis - between 16 and 17 years of age. Besides everything else, this is already a signal that the preventive activities must begin at an even earlier age.

>    By educational level

In 2006 21,4 % of the persons who demanded treatment had lower than secondary, and 5,5 % - higher degree education.
As a whole it could be noticed a relative increase of the total educational level of the persons who demanded treatment. On the other hand, the share of the students (school and university students) diminished from 13,0 % in 2001 and 14,6 % in 2002 to 9,9 °A in 2006.

D    By occupation

In 2006 a fourth (25,2 %) of the persons who looked for treatment has had a permanent job.
Data shows a significant improvement on this indicator. In the interval of six years, the relative share of the clients with permanent job trebled — from 9,3 % in 2001 to 25,2 % in 2006. On the one hand, this is a good sign because it shows reduction of the social harms and of the marginalization of affected population, but on the other hand this shows the extension of the problem beyond the economically inactive population and in this way suggests of a new type of social problems.

D    By ethnic groups

In 2006 93,8 % of the persons who looked for treatment were Bulgarians, 5,3 % - of Roma ethnicity, the rest — representatives of other ethnic groups (in 2001 — respectively 89,7% and 9,6 %).
It is not possible to formulate a definite trend regarding the treatment demanding persons in the last five-six years.

By the characteristics of drug use

Frequency of use

In 2006 81,7 % of the treatment demanding persons have used the primary drug daily.
It is not possible to formulate a definite trend regarding this indicator in the last years.

Pattern of use

In 2006 81,9 % of the treatment demanding persons have injected the primary drug. There is some increase of this proportion, which were in the last five-six years within the limits of 75-77 %.

Continuation of use

In 2006 around two thirds (68,8 %) of the treatment demanding persons were with an experience of primary drug use for more than 5 years.
The increase in comparison with 2001 is more than three times — five years ago this share was 20,7 °hi. Even more significant trend could be noticed among clients with more than 10 years experience in the drug use — their share has grown ten times (from 1,3 °A to 13,1 %). This fact could be perceived as a sign of even weaker rejuvenation of the population of the problem drug users in Bulgaria or, in other words, this could be a sign of decrease of the newly appearing problem drug users, at least regarding the heroin.

Risk behaviour

In 2006 more than half of the treatment demanding persons (56,6 %) have shared at least once in their lifetime used needles and/or syringes.
The comparative analysis for the last six years shows that after the increase of this share, which pick was in 2003 (60,2 %) a gradual drop followed in 2005 and the level from 2001 was reached approximately (50,1 %), and we have again small increase.

Social and cultural context

In 2006 14,1 % of the treatment demanding persons have lived with a person / with persons who uses drugs;
There was a relative decrease of this share until 2005 (around 9 %), and in 2006 the value is near to that from 2001, which was 16,4%.

In 2006 the first treatment demanding persons were 17,0 % of all treatment demands.
The gradual decrease of this relative share from around 50 % in the second half of the 90's to 30 % - 40 % in the last 3 years and around 27 % in 2005 could mean relative "closing" either of the problem drug users group as a whole, or at least of the persons in treatment.

The data from the treatment demand for the first time in 2006 show some basic features of the group profile of the persons demanding treatment for the first time. Below are described some of these features.

By type of drug

In 2006 92,3 % are with primary problem drug heroin.
Obviously, among persons demanding treatment for the first time the heroin remains the most widely spread drug. Anyway, the relative share among them is with around 6 points lower than in all treatment demands. In addition to this the share of the cannabis users is higher and the share of the synthetic stimulants users is also higher among newly emerging in the treatment system persons.

By gender

In 2006 16,4 % were women.

By age

In 2006 11,0 % were up to 19 years of age included, and 90,7 % - up to 29 years of age (total mean age 24,4 years).

By age of first use

In 2006 51,3 % have declared that they had started the use of the primary problem drug at the age of up to 19 included, 6,4 % - up to 14 years of age included; total mean age at first use - 19,7.

By educational level

In 2006 20,1 % had lower than secondary, and 6,4 % - higher educational level.

By occupation

In 2006 approximately every fifth (20,1 %) had a permanent occupation.

By ethnic groups

In 2006 89,3 % were Bulgarians, 9,1 % - of Roma ethnicity, the rest were representatives of other ethnic groups.

Frequency of use

In 2006 81,6 % used the primary problem drug daily.

Patterns of use In 2006 69,6 % mostly injected the primary problem drug.

Continuation of use

In 2006 approximately two of every five patients (39,9 %) had an experience of more than five years of the use of the primary problem drug.

Risk behaviour

In 2006 around one third (33,6 %) shared at least once in their lifetime used needles and/or syringes.

General Characteristics and Patterns of Use from Non-Treatment Sources

According to the data from the National Service "Police" at the Ministry of Interior in 2006 the divisions of the national police have registered in the country a total number of 3 792 drug users (only users + users and dealers) 47. The information comes from a routine police registration system, which covers all the regional offices in the country and is national by coverage. The registered are persons (not cases), and double counting is practically excluded.
A total of 909 from indicated 3 792 persons who use drugs (24,0 °/0) have also been engaged in dealing drugs. This means that approximately every fourth registered from the police for drug use is in the same time a dealer, too. On its part, this fact speaks for the partial merging between the health and the legal aspect of the problem on social level. Nearly 2/5 of the registered persons (1 543 persons or 40,7 %) were minors 48 or under-aged 49, which seriously directs the attention towards the question of the drug use among teenagers in Bulgaria.

From the viewpoint of the type of drug more than half of the persons (2056 or 54.2 (Y.) are registered in relation with the use of cannabis, 1091 (28,8 °/0) — in relation with the use of heroin, 547 (14,4 %)— of synthetic drugs, and 98 (2,6 %) — of cocaine (see Figure 4-2).

36 See also the Annual Report 2005 of the National Focal Point for the EMCCDA

37 See the three Standard Tables 8 from 2005

38 Report for the work of the divisions of the National Service "Police to Ml along the line "Drugs" generally for the country for the period 01.01.2006 - 31.12.2006 (unpublished)

39 See Profile of the persons demanding treatment in the same chapter.

40 See the same.

41 See also Standard Table 8 for problem use from 2005.

42 More details for this estimate are available in the Annual Report 2005 for the situation of the problems regarding drug use, NFP and NDC

43 See also Standard Table 8 for problem use from 2005

44 See also the Annual Report 2005 for the situation of the problems regarding drug use, NFP and NDC

45 See also Standard Table 8 for problem use from 2005

46 Sofia, Plovdiv, Varna, Pleven, Veliko Tarnovo and Radnevo.

47 These and the following data: Report for the work of the divisions of the National Service "Police" at Ministry of Interior in regards of the "Drugs" line for the period January 01, 2006— December 25, 2006

48 Under 16 years of age, incl.

49 Under 18 years of age, incl.

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