5. Drug-Related Treatment

In this chapter will be reviewed the prerequisites and the options for treatment in relation to drug use which existed in the country in 2006. Our attention will be focused mainly on:

•    The system of treating addictions;
•    Drug — free treatment;
•    Drug — assisted treatment.

The most widely spread options and forms of treatment of problems related to drug use in Bulgaria will be presented in short.

As an introduction it should be noted that in relation to the implementation of the Strategic Task 6 from the National Strategy of Combating Drugs 2003-2008 („Providing an Easier Access to Effective Treatment Programs") the National Centre for Addictions (NCA) started working out a system for referring patients. Different types of registers are compiled and kept at the National Centre for Addictions (NCA) so that the co-ordination among the different treatment programs could be improved and the options for information- broadened.

In 2006 the NCA obtained a certificate for an Administrator of the personal data from the Committee on the Personal Data Protection. The program product ensures personal data protection for the patients.

In 2006 the work of the NFPDDA to improve the co-ordination among the treatment programs and to enhance the capacity and the knowledge of those working in the field of prevention, treatment and rehabilitation of addictions, continued. 50

Treatment System

The diagnosis Drug and Alcohol Addiction is made according to the criteria of the International Classification of Diseases, 10t° revision (ICD - 10) and in this sense the ICD-10 addictions are a part of the psychic health.

The medical activities to treat addictions of outpatients are paid for by the NHIF. The funding of,the inpatient psychiatric care at this stage is made from the republican budget, via the Ministry of Health and the municipal budgets. Regulation Ng 40124t° November 2004 for specifying the main package of healthcare activities, guaranteed by the NHIF, provides that among the activities executed by the general practitioner are also the prevention and diagnosing of addictions. Since the addictions are a subject of the specialty Psychiatry, the healthcare activities, included in the package of the Psychiatrist from the outpatient healthcare concern also the patients with addictions. The treatment of the patients addicted is carried out by specialists- Psychiatrists who work in multidisciplinary teams.

In case of emergency /intoxication, etc./, the emergency treatment is done at the Centers of Emergency Treatment and from there the patients are referred to the Departments in Toxicology, or to the Intensive Care Units, or other hospital departments if necessary, depending on the diagnosis.

On the data of the National Health Statistics for 2006 at the specialized inpatient healthcare establishments in the country 1971 patients diagnosed as suffering from psychic and behavioral disorders caused by the use of other psychoactive substances (see Figure 5-1) have been treated. For the period 1990-2006 when observations were made this is the greatest number of patients hospitalized. The trend of increasing the number of hospitalized patients still holds. The greatest number of patients hospitalized was registered at the Regional Dispensaries of Psychiatric Diseases with clinics - 879, followed by the psychiatric clinics and the state psychiatric hospitals. Under dispensary observation are the following groups of patients: diagnosed as suffering from "Psychic and behavioral disorders caused by the use of other psychoactive substances" —916. 51

The total number of beds in the health establishments for psychiatric treatment is 5 439 and 201 out of them are set for patients with addictions.

Alongside specialized forms of organization and technologies of treatment are developed: programs for substitution treatment and maintenance treatment with opioid agonists for patients with heroin addiction, rehabilitation programs of the "day care" or "day center" type and therapeutic communities.

The treatment of addicted patients is based on two main principles: drug-free treatment and drug-assisted treatment.

Drug - Free Treatment

Drug - free treatment is a psycho-social therapeutic approach, aimed at full psycho-social recovery and re-integration of the addicted person, whose medicinal treatment is minimal. An important fact is all the greater participation of the NGOs in this process. The main objective of those programs is to help the addicted persons in for ever changing their way of life through the traditional norms and values like mutual help, team work, honesty, care and respect for the other members, responsibility, gratefulness, etc. Another principle is to create safety and security for the participants in the program, which is achieved by observing strict rules.

An important part of the whole rehabilitation program is the re-socialization program. Its main objective is for the changes achieved to be transferred and confirmed in the social context.

The activities of the re-socialization programs are aimed at supporting social adaptation, helping in the process of finding work, helping in solving problems of emotional and interrelationship nature.

Another important part of the rehabilitation programs are the programs for work with parents and relatives and friends. The aim of these programs is to involve the parents and friends of the addicted person in the process of rehabilitation from the very beginning. The activities are related to providing information on addiction, on the principle and the stages of the treatment, emotional support and re-directing of the parents and relatives to care about themselves. The relationships between the family and the addicted person should be changed into relationships between partners and helpers in his/her process of rehabilitation. The whole rehabilitation program includes the personal change of the addicted person, the social context and his/her adaptation to it, the family milieu as the main supporting factor.

The treatment programs, based on this approach, follow the stage of detoxification and are of two main types:

1. Residential - Therapeutic communities
2. Programs for outpatients - Day centers in the communities

Residential programs

In Bulgaria there are two licensed therapeutic communities - "The Phoenix" house in the village of Brakiovtsi and the "New Start" home in the village of Bunovo. The total number of addicted persons they can house is 30. The "Phoenix" therapeutic community is a rehabilitation program for treating addictions and alcoholism. The sectors in the program are: Admission Center, Therapeutic Communities and a Re-Socialization Center.

Programs for Outpatients

Treatment for outpatients is done at services for treating outpatients at the Regional Dispensaries of Psychiatric Diseases with Clinics. Specialized day centers function in Sofia, Varna, Plovdiv: Day Center at the State Psychiatric Hospital for Treating Addictions and Alcoholism, "Solidarity" Day Center at the group practice "Outpatients' Department of Specialized Medical Aid-Psychic Health Center - Varna" Ltd., rehabilitation and re-integration center for addicted persons of the "Project Butterfly" Association, and "Perspectives" Day Center. The total number of persons they can enroll is 75.

The day center at the SPHTAA is the last stage of the model program for successful treatment and re-socialization of patients who have been subjected to detoxification at hospital and have completed midterm hospital rehabilitation program. The "Solidarity" Day Center works after the program and it is under the supervision of the "Trempolin" therapeutic community. The program is a model of intensive treatment whose aim is to achieve behavioral reconstruction from dysfunctional to a more functional behaviour.

The Day Center of the group practice "Outpatients' Department of Specialized Medical Aid-Psychic Health Center - Varna" Ltd. provides different types of services for the addicted patients in the stage of their emotional and behavioral stabilization.

Providing a protected lodging for patients who have successfully completed the hospital programs for treating addictions represents an important element from the development of the modern system of rehabilitation in the country. "Protected lodging" for the patients from the Day Center of the State Psychiatric Hospital for Treatment of Addictions and Alcoholism has been set up and funded by the National Strategy.

Medically - Assisted Treatment

Abstinence Treatment

Abstinence treatment is the main form of treatment provided to the patients from the country. There is a setting for outpatients and for inpatients. The abstinence treatment of outpatients is done at the Regional Dispensaries of Psychiatric Diseases with Clinics (on the data from the inquiry in 8 out of the 12 RDPDC) and the different outpatient services for specialized psychiatric help. Detoxification of inpatients is done at the state psychiatric hospitals at the departments of Psychiatry at the Multi-profile Hospitals for Active Treatment (on the data from the inquiry, carried out in 7 MHATs) and at the Military Medical Academy.

Substitution Treatment

By adopting the Program of Methadone Maintenance Treatment in 2003 a system of programs for substitution treatment was started which are realized at specialized centers. The main type of substitution treatment is the treatment by methadone hydrochloride and substitol. At the beginning of 2006 a National Program for the Development of a System of Methadone Maintenance Programs in the Republic of Bulgaria for the period 2006-2008 was adopted by the Council of Ministers. The program is based on the experience of the European counties and it is in compliance with the main priorities of the European strategy on drugs for the period 2005-2012. The strategic goal of the program is: reducing drug use and the related health and social risks via the development of a system of effective and accessible programs for methadone maintenance treatment.

Methadone hydrochloride is a registered medicinal product in the country and it is purchased by financial resources from the National Program for the Development of Methadone Maintenance Programs in the republic of Bulgaria for the period 2006-2008.

Another substitution medicine in the country is Substitol, which has been registered in the country and is prescribed on special prescription forms for narcotic substances.

The programs for substitution and maintenance treatment are started by permit of the Minister of Health under the conditions and terms of Regulation Ng 24 from 31st October 2000 (promulgated in State Gazette, issue 91 from 7"1 November 2000)

In the process of the program implementation 6 programs for substitution and maintenance treatment with methadone were started — 5 in Sofia, 1 in the town of Varna and 1 in the town of Plovdiv, with a total number of patients included — 1555

In 2006 for the first time monitoring was carried out on the efficacy and the activity of CPP, in the process of implementing the National Program for the development of a system of methadone maintenance programs in the Republic of Bulgaria for the period 2006-2008.

On the data of the monitoring report the CPP currently functioning are very effective. The patients are in a good general and psychic condition, their social behaviour is improved and their criminal activity is reduced. Their participation in the CPP is a prerequisite for the reduction of the prevalence of the blood-borne infections.

At the end of 2005 the medical product Naltrexon was registered. At some of the dispensaries of psychiatric diseases with clinics programs were started for maintenance treatment with Naltrexon

50 Source: Report on the implementation of the Action Plan of the national Strategy for Combating Drugs for 2006, Directorate Coordination and informative-analytical activities (CIAA), Ministry of Interior, 2007

51 Source: National Center of Health Information