Drug Abuse

7. Responses to Health Correlates and Consequences

Prevention of drug-related deaths

Overdose prevention

A great part of the cases of lethal overdose among the drug users can be prevented. In a situation of stigmatizing and criminalizing of drug use a greater number of the cases of overdose can have a fatal outcome because of fear and objection to seeking help. Calling an ambulance from the Emergency Center may not be done because of the fears of the problem drug users present that a team of the police may possibly arrive as well. In this case the training of the drug users themselves in diagnosing and adequately reacting to the overdose and giving first aid are of vital importance.

The following reasons can be defined as main risk factors for an overdose:

Injecting drugs;
Opioid use;
Heroin use in combination with substances suppressing the nervous system;
Loss of tolerability (after a period of abstinence or of reducing the use);
When the injectors are alone (there are no other people present at the moment of injecting).

The problem drug users who are not treated and cannot receive information and knowledge from their attending physician are a target group of the NGOs working to reduce the harm caused by drug use. The outreach practices are the most effective for work with them. The ideology of this method is that groups which for one reason or another do not have an access to the services offered may be encompassed if the services are offered within the target communities. At the communities of the problem drug users specific services are offered depending on their needs. The services are constantly being adapted to the changing circumstances. The organizations are trying to include people from the respective risk groups in all the activities, in which these people can work as collaborators.

The activity of these NGOs refers to the implementation of the "Prevention and Control of HIV/AIDS" program funded by the Global Fund to fight HIV/AIDS, malaria and tuberculosis, and more precisely, to the implementation of Component 4 - Maintaining low level of HIV prevalence among the injecting drug users. Alongside the teams of the programs make detailed explanations to the lals how to inject safely, and they also describe the symptoms of an overdose and how to react correctly in case of an overdose.

The activities aimed at preventing the drug-related deaths are as follows:
•    Training for a safer drug use;
•    Training how to give first aid;
•    Applying antagonists, etc.

In 2006 the "Initiative for Health" Foundation continued to work on the principle of outreach, and to the previous ones new sites of field work were added (for the last year they numbered 13). In the month of May the "Initiative for Health" Foundation established the first drop-in center in Sofia for drug users to cope with the need of organizing low-threshold programs. This drop-in center could serve as a model for similar practices in the town. In the month of May 2006 a second drop-in center of the foundation was established, which was meant mainly for drug users from Roma origin. It is open every week-day and a social worker is always present there, who receives and services the visitors. There non-formal training of the drug users and of the sex workers — men and women - is done.

At the drop-in centers every visitor can be given:
-    sterile needles and syringes and he/she can also return the used ones;
-    clean materials for injecting /caps, filters, citric acid!, disinfectants;
-    condoms;
-    Information materials on safe injecting, prevention of HIV/AIDS, hepatitis, sexually transmitted infections, overdose, etc.;
-    information on the medical services.

At the two drop-in centers of the foundation information can be received on how to reduce the risk of drug use, as well as on the options of treatment or testing for sexually transmitted diseases. Only the outreach field in the "Fakulteta" district was dropped out because its patients were in fact the same ones as those of the new drop-in center. There is a mobile medical surgery functioning as a part of the work of the foundation where tests and field work 56 are done.

The "Dose of Love" Association in Bourgas 57 in the last year also successfully maintained activities to prevent overdose. The organization is still the only one to work with active drug users and with active sex workers. The outreach practice is till maintained as a method of work with the target groups. In the previous year work was done with 536 different clients of the program in 35 different fields.

The "Dose of Love" Association also established the Day Center for Drug Useri'. There the clients of the program can stay, can talk to social workers, can have coffee or tea, or vitamins. This site is very important for the recreation of the social behaviour and for establishing habits of mutual confidence between the users and the team working with them. At the Day Center are provided: information, brochures, condoms, needles and syringes, and if necessary psycho-social consultations of the clients and their relatives are held. At the Day Center bringing in and use of drugs is not allowed. There certain rules are observed, ensuring the order and the security of the clients and of those who work there.

As concrete activities can be indicated the needle and syringe exchange and the dissemination of information materials. The activities of the mobile surgery continue to be implemented in 2006 as well. 751 health consultations have been held, 487 individual and 264 group consultations. The activity of the only one of its kind Drop—in Center in the town also continues.

The methods to access the target groups through "gatekeepers" and "peer-hired collaborators from the target communities represent a new element in the work of the foundation. "Prevention of the health risk of sexually transmitted diseases and other infections among persons in imprisonment" project was won and implemented and within the frames of the project information brochures were distributed. The total number of the brochures distributed is 581.

The teams of the "Panacea" Foundation in Plovdiv have also done activities for the implementation of the outreach program: providing training in safe injecting techniques, distributing materials for safer injecting, psycho-social work done among the addicted persons, referring for consultation and treatment to the specialized surgeries — more than 400 patients have been referred to such surgeries. The teams work in a total of 17 fields and drop-in centers. All who work in the teams have been trained to work for harm-reduction in the risk groups. Contacts have been made with 466 new for the program injecting drug users.

The consultations where the risks are explained and knowledge is provided on safer techniques of injecting and safer sexual contacts were conducted either with groups or with individuals. Their number for 2006 was 1 959. On a daily basis discussions with the program clients were held on different topics - including the prevention of infections and of overdose.

Materials containing health information on AIDS, overdose, hepatitis and types of substances have been distributed in a total number of 1 700 58.

The "Public Charity Fund" Foundation in Blagoevgrad also continued its activity from the past year of needle and syringe exchange and of work among the addicted persons to enhance their knowledge of the risk they run. A number of 586 contacts have been organized with the drug users. 3 580 number of syringes and 7 615 number of needles have been distributed. The team works among the addicted persons with the aim of enhancing their knowledge of the health risk they run so that a denial of such behaviour can be motivated or at least reduction of the risk practices can be achieved.

One of the significant problems for the outreach workers is the frequent presence of police employees in the field where the contacts are realized, which greatly reduces the chance of adequate contact between the team and the clients 59.

The Foundation "For a Better Psychic Health" in Varna has realized 3 416 contacts, of them 583 — primary. The team has experience and knowledge on how to work with injecting drug users. There is a Drop-in Center established as part of the work of the foundation and the most suitable premises is used for it. The respective share of contacts realized there makes for 78,7% of the total number of contacts. 60 971 number of syringes and 121 942 number of needles have been provided.

645 individual consultations and 380 group consultations have been conducted, and more particularly on safe injecting techniques —658.

The field collaborators seek for and establish new sites for injecting, but they report that contact with the clients is difficult to realize. The supply with drugs is already done through preliminary bargaining on a mobile phone. Another difficult moment in their work is the patients' reluctance to receive the results from the tests they have done for the blood borne infections. This illustrates the need of preliminary work to motivate the clients 69.

In the town of Pernik the "P.U.L.S." Foundation is also working after the method of outreach and for the previous year they realized 1 835 contacts with problem drug users. 14 748 needles, "9 174 syringes and 2 021 caps have been exchanged. 3 673 condoms have been distributed, 1 684 packages of citric acid and a lot of health information materials. (see Figure 7-1).

The members of the organization of the Bulgarian Red Cross in the town of Rousse also exchanged needles and syringes in 2006 - 15 980 needles and 12 569 syringes. Members of the Red Cross worked after the outreach method at 9 key sites. 1 690 contacts have been made, of them 183 were unique (37 women and 146 men). The mean age of the clients was 18 — 37 years. A lot of written materials on the health risk run have been distributed. A not insignificant circumstance for the successful work is the calm and pleasant atmosphere at the office, which predisposes the clients to the program. The team establishes contacts with different institutions - Regional Inspectorates of Environment and Public Health Preservation and Control, MHAT-JSC, Prevention and Information Centers — aimed at a better coordination and a more appropriate realization of the objectives of the problem 61.


The organization of the Bulgarian Red Cross in the town of Stara Zagora has a similar activity. Maintaining constant contacts with the drug users is what characterizes the activity of the organization. The contacts are based on anonymity and mutual confidence. Personal cards are issued, certifying the clients' participation in the outreach program 62.

Karitas - Sofia has been working for 7 years after the Project "Mobile surgery for persons addicted to psychoactive substances." Within the framework of the project have been set and held consultations on health problems and primary healthcare has been provided to those in need. As main objective for its work the organization points out motivating more drug users to change their conduct, to limit the blood/sexually transmitted diseases, so that the social attitude towards the drug users can change. The organization has planned expansion of its activity by establishing consulting centers in the towns of Sofia, Bourgas, Pernik, Nova Zagora, Plovdiv. Karitas in Sofia is studying the possibility to establish a day and night center for people abusing drugs. 3 574 visits have been paid; new (initial) contacts have been established with 259 persons. The team estimates as difficulties in the work the reduction of the number of clients' visits and the reduction of the number of those willing to be tested for AIDS and for hepatitis B and C 63.

Since 1st March 2006 the Regional Council of the Bulgarian Red Cross in the town of Kyustendil has taken up the task of continuing to provide services for the implementation of the program of maintaining a low level of HIV/AIDS prevalence. The BRC in the town of Kyustendil makes regular contacts with the injecting drug users from the Roma district of the town, its members present information, health consultations, distribute needles and syringes and other materials. Contacts have been made with 136 Roma people, the total number of contacts being 2 175. 183 clients have been consulted on how to apply safer injecting techniques. 222 copies of health information printed materials and brochures have been distributed 64.

The distribution of sterile sets for injecting is part of the preventive work of the organization, doing outreach work among the injecting drug users in the country. The sterile sets have been supplied by the Global Fund to Fight HIV/AIDS, malaria and tuberculosis. On table 7-1 the figures for the needles and syringes distributed are given for the different towns in the country for 2006.

Use of opiate antagonist - naloxone

The effectiveness of the work of the emergency centers in the country plays an important role for prevention of fatal outcome from an overdose. Not insignificant is also the fact that when an ambulance is called, a doctor always comes trained for work in cases of overdose. In accordance with Regulation N2 25 from 1999 on the list of medicines applied and in the bag with medicines there is always an opiate antagonist - naloxone.

Naloxone is a medicine used to prevent the effects of opioid overdose - heroin and morphine. Its specific use is related to its especially high affinity to the p-opioid receptors in the Central Nervous System. When injected intravenously its effect starts in 2 minutes and can last for 45 minutes. It is distributed under the trade names Narcan, Nalone or Narcanti.

In some counties the medicine is distributed for use by the problem drug users themselves to prevent a lethal outcome from an overdose. This is not the practice in Bulgaria.

The activities in the country aimed at preventing cases of lethal overdose are still exercised in specific towns implementing the program of the Ministry of Health and of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria. The program has already been enforced in ten towns in the country — the situation in those towns has been assessed in advance and determined as greatly at risk for spreading injection drug use — and the program for prevention and control of HIV/AIDS provides for the IDUs the knowledge how to prevent the lethal outcome from an overdose.

Prevention and treatment of drug related infectious diseases

Prevention

The prevention of infectious diseases related to drug use is a constituent part of both the basic documents adopted by the Council of Ministers of the Republic of Bulgaria - the National Program for Prophylaxis and Control of AIDS and the Sexually Transmitted Diseases for 2001 - 2007 and the National Anti-Drug Strategy (2003 — 2008).

In the Action Plan of the National Strategy the activities for prevention of the infectious diseases related to drug use are specified as Strategic Task 5: "Reduction of the prevalence of diseases affecting society among the drug users: blood borne infections(HIV/AIDS, hepatitis B and C, etc), tuberculosis and diseases transmitted sexually, etc".

The following sub-tasks have been set:

Training teams for field work with drug abusers;
Working up and applying programs for field work, needle and syringe exchange, distribution of condom, consultations;
Identifying the problems and preparing programs to reduce the risk in particularly difficult to access and high-risk groups;
Programs for early testing (including in the field), pre- and post-test consulting and referring for specialized treatment.

All the organizations working in field should present their projects to the medical board of the NCA (in accordance with Regulation Ng 30 from 20th December 2000 of the Minister of Health).

In 2006 10 not-for-profit organizations undertook activity for the prevention of HIV/AIDS, hepatitis B and C among the IDUs and they have been delivered with positive opinion by the NCA for doing these activities, namely the Programs for Field Work, needle and syringe exchange and testing for blood borne and sexually transmitted diseases within the frame of component 4 "Maintaining a Low Level of Prevalence of HIV among the IDUs after the Program of the Ministry of Health "Prevention and Control of HIV/AIDS, Malaria and Tuberculosis", funded by the Global Fund, as follows:

"Initiative for Health" Foundation - Sofia

"Panacea" Foundation - Plovdiv

"Dose of Love" Foundation - Bourgas

Pleven

"Health and Social Development" Foundation

Bulgarian Red Cross - Rousse, Kystendil and Stara Zagora

"For a Better Psychic Health" Foundation — Varna

"P.U.L.S." Foundation - Pernik

"Public Charity Fund" Foundation — Blagoevgrad

"Health and Social Development" Foundation - Sofia

The mobile medical surgeries are supported by 5 NGOs after Component 4 and by KARITAS - Sofia, as well as by the organization "Physicians without Borders".

Consulting and testing

Testing for HIV/AIDS in Bulgaria is free. The laboratory of the NFPDDA has been established to provide service to drug users. The kits for these tests are supplied by the Ministry of Health.

The addicted persons who are health-insured can have the tests also via the health insurance system.

In 2006 18 surgeries for anonymous and free consulting and testing for HIV/AIDS continued functioning in the big towns of the country.

Since 2000 in the Republic of Bulgaria no immunizations have been given to the drug users against hepatitis B or hepatitis C. In Sofia the KARITAS NGO gives free immunizations to the IDUs, but the number of those immunized is very small (for 2006 - 19 persons). Since 1992 a free and compulsory immunization against hepatitis B has been given to all new born infants.

Treatment

All the persons infected with HIV as well as the patients with AIDS are free - treated at the specialized department of the Hospital of Infectious Diseases in Sofia, as well as at the departments of Infectious Diseases for AIDS Treatment in the towns of Plovdiv and Varna. To the infected patients addicted to opiates free and immediate treatment is provided after the program of maintenance treatment at the Specialized Psychiatric Hospital for Treatment of Alcoholism and Addictions /SPHTAA/ — Sofia and after the regional programs in Plovdiv and Varna.

The treatment of the addicted patients infected with hepatitis C is funded by the NHIF. According to the requirements of the NHIF the persons addicted to drugs may be included in a program for interferon treatment if they have not used drugs for the last 6 months. The persons who are not health insured have no access to the treatment of hepatitis C. The treatment of those who have been approved by the NHIF is done at the Departments of Gastroenterology in different hospitals in Sofia but the data we dispose have not been confirmed. The treatment of patients with acute and chronic form of hepatitis B is accessible only for health insured addicted persons.

The treatment of syphilis is regulated; it is done at the Dermatology and Venereology Dispensaries in the regional towns in Bulgaria and is free of charge.

56 More on the activity of the foundation at its address: httpliwwwinativeforhealth.org/

57 More on the activity of the association at the address: littpliwww.doseoflove.hit.bg

58 Source: Report of the "Panacea" foundation for 2006

59 Source: Information reference on the activities of the "Public Charity Fund" foundation in BIagoevgrad for 2006

60 Source: Annual report of the For a Better Psychic Health" foundation for 2006

61 Source: Information on the activity of the BRC in the town of Rousse on component 4 "Maintaining low level of HIV prevalence among IDUs over the period 19t January — 319t December 2006

62 Source: report on the Project of harm reduction — the town of Stara Zagora

63 Source: The annual report of the "Mobile surgery for work with persons addicted to psychoactive substances" Project

64 Source: Report of the Regional Council of the Bulgarian red Cross in the town of Kyustendil for the course of implementation and the results achieved after Component 4 from the "Prevention and Control of HIV/AIDS" program for 2006

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