Boltushka: Use of Homemade Amphetamine in Odessa, Ukraine Repsina Chintalova-Dallas [1] Dmitry Lutzenko [2] Zita Lazzarini [1] Patricia Case [3] [1] University of Connecticut Health Center, USA; [2] Charity Fund “The Way Home” Odessa, Ukraine; [3] Fenway Community Health Center, USA NIDA/NIH Grant # 5 R01 DA17002-02

Odessa, Ukraine Odessa is the third largest city in the Ukraine (Pop. 1.1 million); One of the first rapidly escalating HIV epidemics in Ukraine and Eastern Europe, most cases attributed to injection drug use; 7,822 officially registered drug users in Odessa; Estimated real number ranges from four to five times higher (31,288 - 39,110) [1] Source: S. Matic, J. V. Lazarus, M.C. Donoghoe “HIV/AIDS in Europe: Moving from death sentence to chronic disease management”, WHO/Europe 2006

Homemade Amphetamines have a long history in Eastern Europe 1980’s: Efforts to control Roma villages distributing opium resulted in police raids in Ukraine starting in late 1980s. This increased the price of opium and caused the shift to cheaper amphetamines 1980’s: Users began making “Vint” – a homemade preparation containing methamphetamine and obtained via ephedrine reduction 1990’s: Users began making Boltushka using a less complicated process. Boltushka is homemade preparation containing methcathinone. Pseudoephedrine-containing cold medications oxidized with KMnO4 produce Boltushka. 1990’s: In the effort to control homemade amphetamines, ephedrine was regulated. Now drug users use cold medications containing PPA and the same oxidation process to produce cathinone, a weak amphetamine. The drug is still called Boltushka or “mix”.

Rapid Policy Assessment and Response (RPAR) Collect laws and epidemiological & criminal justice statistics Action Plan 3 focus Groups Community action & change Analysis Report Key Informants 24 in “system” 14 IDUs Organize CAB* CAB 1 CAB 2 CAB 3 CAB 4 CAB 5 CAB 6 CAB 7 *CAB includes participants from law enforcement (police, judiciary, prisons), public and private drug treatment providers, health care (physicians, nurses) and social welfare agencies (Family Support office).

Boltushka Research Methods: Ten interviews with young IDUs (who have used boltushka once in the last three months and were between the ages of 18 to 25); Four interviews with pharmacists; Informal interviews with volunteers at NEP, doctors at Charity Fund “The Way Home” and social workers.

Demographics of Boltushka users N % Male 7 70% Female 3 30% Median age in year (range) 21.3 year 19 – 25 year

Demographics of Boltushka users “Boltushka has become increasingly popular among the very young and very poor of the city of Odessa in the late 1990s and 2000s” [1] [1] Ukraine/Odessa/Interviews 1,3,4,5,7,8 with IDUs/RPAR Project/January 2006 (UKR/IDU/1,3,4,5,7,8)

Making boltushka 10 tablets of cold medicine (Teffedrin, Koldack, Effect) 10 cc of warm water 1 cc of household vinegar 3 – 5 g of KMnO4 (potassium permanganate) Shake or mix until the substance “smells of cherries” Sometimes aspirin is used instead of vinegar (or both ingredients used in half doses)

Availability of Boltushka ingredients in Odessa Ephedrine-containing medicines are only sold with the prescription; PPA containing medicines are sold over-the-counter; KMnO4 is only sold openly in one pharmacy in Odessa, but is widely available at black market; Several pharmacies around the city are “doing business with drug users”; Needles and syringes are widely available and are inexpensive.

Boltushka and its use Cost per dose - <US$1.00; Prepared for personal use only; Mainly used by the very young and poor; Boltushka is a group drug (usually groups of 3-7 people); Usually injected 5-6 times a day (some reported up to 10 times a day); Some IDUs reported to injecting for 2-3 days going without food and sleep; Only injected intravenously (most commonly in arms and legs);

Boltushka and its use “needles and syringes are the last thing to worry about; you need to find money for pills – that’s what’s important. In most cases after having gone a long way to buy the pills and hurrying back home to make boltushka you don’t even remember to think about syringes. There’s at least one person in the group who will have the syringe if you don’t have yours”[1]. [1] Ukraine/Odessa/Interview 4 with IDU/RPAR Project/January 2006 (UKR/IDU/4)

Risk of bloodborne disease Common practice of sharing the equipment; Currently only 2 IDUs use NEP as needles and syringes are available and inexpensive or they can borrow from other people in the group; 9 IDUs confirmed the practice of front-loading; 6 IDUs reported having engaged in an unprotected sex following the injection; At least one respondent stated that boltushka is popular among young and uneducated female commercial sex workers “to make their work easy”; IDUs (aged 11-14) pick up needles and syringes on streets and use them.

Police and boltushka users Police stop boltushka users mainly outside pharmacies, but “usually they let us go the same day because police know they are wasting their time on us as most boltushka users are poor and have no money for bribes”[1]. IDUs reported police use physical abuse against them (most commonly against male IDUs); Pharmacists will help IDUs conceal cold medication from police by switching boxes with other medications. [1] Ukraine/Odessa/Interview 1 with IDU/RPAR Project/January 2006 (UKR/IDU/1)

Reported health effects of Boltushka use Early effects (approximately after 1 month of use): IDUs report “shaking wildly”; Grinding teeth; Abscess and skin burns when injected under the skin After continued long use: Partial loss of cognitive function; Brain damage; Parkinsonian symptoms; Delayed mental and physical development in children age 11-14 who use boltushka

Reported behavioral effects of boltushka use High level of activity and energy; Talkativeness; Reported loss of appetite for 2-3 days.

Interventions for Boltushka users Boltushka users are at probable risk of Hepatitis C and HIV infection because of shared equipment and poor hygiene practices; Apparent need for drug treatment resources directly addressing the needs of boltushka users; Education/treatment specific to boltushka users; Screening for other physical harms to document the drug’s other effects