Economic analysis of drug addiction (examples from Bulgaria) Jasmine Pavlova, Lora Afanasieva, Dimitar Popov, Gabriela Ivanova

(abstract)
Background Nowadays Bulgarian population is facing a number of challenges: economic crisis, demographic ageing and bad general health status. The global burden of mental disorders can be assessed in four ways: prevalence, burden, inequities in the distribution and their impact on other health conditions. Drug use is a significant health and social problems for the world population. The European Union has more than 2 million problem drug users. The incidence of HIV/AIDS among this contingent represents a major challenge to the public health. Purpose: To examine the social and economic reasons for drug abuse and its impact on the society; to suggest how problems of drug abuse prevention and control can be addressed in a constructive, coordinated manner. A study of injecting drug users is conducted in 8 large and medium cities during 5 years period. Results and discussion Authors study the socio-economic conditions and analyze their impact on the mental health and drug addiction. About 5% of Bulgarians have tried any drug. There are a large number of heroin addicts and some existing treatment programs. The implementation of a comprehensive new treatment program for heroin addicts is indispensable. Interdependence between life standard, level of education and health status is found out. Conclusion Serious obstacles to access to health care are the reduced incomes and the increased economic vulnerability of the population. Bad economic and health status are bound into a vicious circle where unemployed people remain out of the health aid scope. As a result poor peoples health limits their access to the labor market, increases their poverty and social isolation. The limited financial resource for the health system has to be allocated and spent more effectively. Treatment of Addiction is insufficiently accessible and effective. Many of the existing treatment programs are private and are therefore financially inaccessible to users.

Drugs history shows that they are used since ancient times. First descriptions around 4000 BC mention how Sumerian tribes are extracting the Opium poppys (Papaver Somniferum) juice and were using it as drink and nutrition supplement. In Egypt the opium was used around 2000 BC. The word opium has Greek etymology and means juice. Important civilization stages are related to rituals and customs involving usage of some kind of drugs. One of the most important reasons drugs use to become a problem is the interconnection with money and euphoria. It is registered in the beginning of 19th century with the mass-production of narcotic (opiates) substances all around the world after 1878. Lately it becomes one of the serious problems for humanity known as The opiums wars. With their desire to increase benefits, European traders try to access the traditional spiritually oriented Asian Fortresses especially India and China. While the English East Indian society trades actively with India,

the goods exchange with China is exclusively unilateral. England had to pay the silk and tea from China only with silver. The humble Chinese on their side didnt need any of the English goods. Thats England became with negative trade balance. In 1794 Chine forbid the opium import in the country. Beside this order opium trading continued and in 1837 it reaches more than 43 000 trunks per year with average price per item around 700 silver dollars. The opium dependence spread around all the country and reach up to 90% of the population. The irony of the worlds history is that former users are becoming todays dealers. It is supposed that China is one of the largest producers of opium nowadays with presumed amount of 6000 to 8000t/year. Behind this historical irony is hidden a considerable change opium became a world trade good. Nowadays Afghanistan is one of the largest producers. Considering the UN report, after the Talibans regime fall in 2001 there is high production growth and it reaches about 60% of the GDP of the country. Nowadays Bulgarian population is facing a number of challenges: economic crisis, demographic ageing and bad general health status. The global burden of mental disorders can be assessed in four ways: prevalence, burden, inequities in the distribution and their impact on other health conditions. Drug use is a significant health and social problems for the world population. The European Union has more than 2 million problem drug users. The incidence of HIV/AIDS among this contingent represents a major challenge to the public health. In the beginning of the new millennium Bulgaria faced the growing problem with drug abuse and addictions which was getting more and more serious in the first years of transition. Thats why in 2003 the government elaborated a National strategy against drugs with an executive program with 5 years (2003-2008) duration. We analyzed this programs database and compared its results with the actual information.

During last years in Bulgaria there have been many researches of the drug dependant people group. The purpose is to examine the social and economic reasons for drug abuse and its impact on the society; to suggest how problems of drug abuse prevention and control can be addressed in a constructive, coordinated manner. A study of injecting drug users is conducted in 8 large and medium cities during 5 years period. This allowed making demographic and socio-economic profile of the group. At first place drug use compared between genders shows that male users are 4 times more than females (Chart 1), which again demonstrates the cultural basis of the phenomenon.
Chart 1. Drug users by gender

90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2003 2005 2007 2003 Female Male 20% 80% 2005 17% 83% 2007 17% 83% Female Male

Female Male

The research in Sofia, Plovdiv, Varna and Kjustendil shows that around 23% of the group belongs to the roma ethnos and 7% of the users declare Turkish ethnicity (Chart 2.).

Chart 2. Users by ethnic group

6,60% 23,10%

Bulgarians Romas Turks

70,30%

In comparison to the stable state of genders participation there is a clear change in the age structure of the group with a tendency of increasing the part of people administrating i.v. drugs with higher age and less younger subjects (Chart 3). The tendency that the group is getting older is even more obvious if we compare the average age of the users by years: in 2003 24 years, 2005 25 years, 2007 27 years. The average age of the users is different in different cities with higher age in the bigger cities (with maximum in the capital Sofia 31 years). The explanation of these differences is that the heroin abuse started from the capital and the bigger cities and then spread to other smaller cities within the years.

Chart 3 Age tendencies among the drug users.

In addition to that the group is getting older is the fact that nearly half of them didnt graduate high school and 13% dont have any education (Chart 4). Their situation at the labor market is worsening and more than 60% are unemployed and every 5th of them doesnt have any ID. In 2003, 49% of them didnt have a health insurance, in 2005 43% and now 39% dont have one. These factors are getting more and more evident the marginalization of these people and demonstrate how the most important social spheres education, labor, health are inaccessible for them.

Chart 4 Education profile of the drug users

Higher Education

2%

High school

48%

Secondary school

24%

Primary school

13%

Without education 0% 5% 10%

13%

15%

20%

25%

30%

35%

40%

45%

50%

This future marginalization will multiply the health and social problems making rehabilitation and resocialization for users and ex-users harder. From a point of view what is the access to specialized treatment of addiction, all the social factors are diminishing the chance of these people for access to treatment programs and their eventual reintegration as a well-functioning individuals. Nearly 70% of the drug abusers are using not only heroin but in combination most frequently with marihuana followed by methamphetamine. This make the challenge of curing opiates dependencies more difficult for physicians which have to treat addiction not to one but several substances. In addition to the drug poly-consummation is the risky behavior and the increased incidence of HIV/AIDS, HCV and HBV infections. Most of the addicted are used to some dangerous practices 62 % says that at least once in their life they used a shared needles or syringes, 74 % used common spoon, filters or water, and 56 % separated doses in a used syringe. Treatment programs and programs for distribution of sterile needles and syringes are still not enough effective to diminish the HIV/AIDS incidence. The problem is obviously much more

complex and needs responsibility and active position to find a working solution for this not only personal problem, but of the families, health specialists and the whole society. Results and discussion Authors study the socio-economic conditions and analyze their impact on the mental health and drug addiction. About 5% of Bulgarians have tried any drug. There are a large number of heroin addicts and some existing treatment programs. The implementation of a comprehensive new treatment program for heroin addicts is indispensable. Interdependence between life standard, level of education and health status is found out. There are two major ways to treat drug abuse in the world. The first is to act as it is a severe crime or sin and the only option is to eradicate it from the society. The second is to accept that drug addiction is sickness and to help people with this problem you have to cure them. In many countries when drug addicts are ready and want to get cured and continue their life health system propose them multi-professional aid and support. When they are still not at a point to realize their need of help, society doesnt reject them, but physicians from Anti-drug programs prescribe them the needed drug dose to avoid abstinence syndrome and to give them a chance and support to get safely to a treatment program. In conclusion sickness is much more unattractive than sin. Thats way most of the societies are developing such treatment programs for hard drug addictions in particular those for heroin with controlled methadone substitution. The methadone is one the well-known synthetic opiate used for heroin substitution. Its way of administration is per orally thats why it reduces the incidence of blood-transmissible diseases. It has long acting effect and allows to be taken once per day. Methadone has no euphoric effects and its abstinent syndrome is longer but much easier to handle. Treatment usually starts with 80-100mg doses with the perspective of step-by-step reducing of the daily

doses. The success of each program is based not only on the drug substitution but in multi-professional health, psychotherapeutic and social support. The latest information about the costs of such interventional programs in Bulgaria is 27 712 euro (54143 levs) for 100 addict patients for one year. These costs are comparable with the only detailed information on this subject given from R.J. Caplenorn and coll. /1995/ 35-42$ per patient, per week in Australia. The main problem in evaluating costs and effectiveness of these Methadone substitution treatment programs is that some of their parameters are hard to be defined and estimated. Suffering, grief and death are hard to be evaluated as a burden in humans life and society loss. Most of these programs and temporarily functioning depending on project financing or other programs being private. Patients are facing a vice circle being unable to pay such price and are forced to quit the treatment returning to their previous way of living. Conclusion Serious obstacles to access to health care are the reduced incomes and the increased economic vulnerability of the population. Bad economic and health status are bound into a vicious circle where unemployed people remain out of the health aid scope. As a result poor peoples health limits their access to the labor market, increases their poverty and social isolation. The limited financial resource for the health system has to be allocated and spent more effectively. Even the high direct and indirect costs for heroin addiction treatment in health and social sector we consider the drug abuse as a social important problem. Treatment of Addiction is insufficiently accessible and effective. Many of the existing treatment programs are private and are therefore financially inaccessible to users. Investing in prevention programs and financing such substitution treatment programs will reduce two to three times the further treatment costs for these patients.

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