Mass use of legal highs causes HIV rise in Romania

A feature on the rise in HIV in Romania among drug users published in UK charity Drugscope’s magazine Druglink in March/April 2013 http://www.drugscope.org.uk/publications

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In Romania, following a switch from heroin to legal highs among injecting drug users, new cases of HIV have boomed
By Michael Bird

Cristi is dressed in a baseball cap, with holes in his shoes and a Nike top where the tick insignia on the chest has loosened. Blisters litter his arms and face and his nails are encrusted with dirt. “I am 22 years old,” he says. “I know I look older.”
Since his mother died in 2005, he has lived on the streets of Romania’s capital, Bucharest, gaining cash from selling scrap metal. “Pipes, old washing machines, sewing machines, door-locks, batteries or copper wires – whatever I can find,” he says. “Some people give me different kinds of metal. They give them to me because I do not steal.”
Cristi has taken heroin since he was 12, but last year switched to injecting legal highs sold in head shops, including powdered stimulants posing as bath salts.
“I inject both legal highs and heroin, but I’m doing more legals,” he says.
“The first time I took them, I had panic attacks. I saw police everywhere. As time passed, my body got used to it. Now I can control the states. I no longer see cops wherever I go.”
Cristi dilutes a legal, amphetamine type stimulant called Pure by Magic, which he shoots into his vein. “With legals, I get a little bit excited,” he says. “It’s a better sensation than heroin. I can do more work. I manage to make money, while with heroin I just slept.”
Gheorghe, 28, has been a heroin user for nine years, but 12 months ago switched to Pure by Magic. “One bag holds me up for the morning until the evening,” he says. “I also take heroin, but once a week as a special occasion. I would go back to heroin, but it’s too expensive.”
For him, heroin costs around 11 euros per day, while legals give a similar buzz for five euros. “I can spend the rest of the money on food and cigarettes,” he says.
With Romania’s currency collapsing against a weak euro, government budgets plunging into the red and disposable income crashing since 2008, those at the margins of the EU have been pushed further to the edge. The cash available for recycling scrap metal and plastic bottles has been scarce and, among Bucharest’s 18,000 known addicts, legal highs have become the street drug of austerity.
But this culture has also entered the mainstream. In total, the number of legal high users in Romania is around 250,000, while one in six of these are injecting, according to a 2011 study by UNICEF and the Romanian Anti-Drug Agency (ANA).
Experts fear this is contributing to a shock rise in new HIV cases. Because these legal highs are stimulants as opposed to a depressant such as heroin, users need more regular fixes. Cristi injects up to 20 times a day compared to three times with heroin. Without a steady supply of fresh needles, users are likely to share, boosting their chances of contracting HIV.

For 2011, Bucharest’s Matei Bals National Institute of Infectious Diseases registered 129 new cases of HIV among injecting drug users – a growth of almost ten times the figure for 2010. So far 2012 looks worse, with 98 new cases among users in the first six months – hitting disproportionately the age group 20 to 24.
“The spread of HIV in Romania is increasing and a major cause is habitual heroin users switching to injecting legals,” says NGO Romania Harm Reduction Network’s Executive Director Valentin Simionov.
But this new trend has ensnared the drug community at the same time as a fall in the availability of clean needles. The Global Fund to Fight AIDS pulled financing for Romania in 2011, expecting local authorities to pick up the tab for needle-exchange programmes for heroin users. But this didn’t really happen.
While the number of injecting drug users remained stable, free syringes available
plummeted from 1.7 million in 2009 to 900,000 in 2011.
Now there are only two outreach charities distributing needles to addicts, compared to five in 2011. One of these, Carusel, does not have a proper office. Its dedicated volunteers squat in a room above a gay, lesbian and bisexual pressure group.
“None of us has a salary,” says Carusel’s council president Marian Ursan. “I use my own car. We have food donations from friends. Our drop-in centre has no water or toilet. In our office, we have a photocopier – but it’s not second hand, I think it’s third or fourth hand.”
The charity has 30,000 needles donated by the National Anti-Drug Agency (ANA ), but after these run out, there are no fresh supplies. This year ANA bought almost 960,000 needles and syringes for use in 2012. “We intend to continue this purchase in 2013 depending on the financial resources available,” says ANA ’s Director Sorin Oprea.
EU structural funds are also funding the provision of hundreds of thousands of needles to charities to remedy the crisis. But charities still fear an HIV time bomb may strike. Carusel now has 150 HIV tests to sample users.
But Ursan says even he is “afraid” to take these to addicts.
In 2009 hundreds of head shops opened across Romania, selling powdered amphetamine-style stimulants and dried, cannabis-like products. Due to public protests, the government forced shops to close if they were less than one kilometre from a school or a church. Lists of active stimulants and brand names for the drugs also face regular bans, but their producers create new blends to outsmart the authorities.
“When the shops opened, I started buying from them,” says Cristi. “There were these small bags which had an eye printed on them. That was the shit. Until ‘Pure by Magic’ came out, there was ‘Special Gold’, when you were shooting that, your eyes got bigger. You could see right away if someone had shot that. Then came ‘Magic’. Then ‘Flower Power’, ‘Magic Crystal’, ‘Magic Pure’. That was like heroin. Then ‘Insomnia’, ‘Magic Power’, ‘2012’, ‘Atomic’, ‘Ninja’, ‘NOS’, ‘Expression’. Then ‘Euphoria’. That was called sea salt. Then ‘Pure’. That was called talcum powder. One was a cleaning solution for exotic dolls.”

Speedball of the poor

Romania’s Matei Bals Institute for Infectious Diseases sent samples of legal highs on sale in Romania to the UK, where a lab found they contained cathinones such as mephedrone and methylone and also piperazines and methamphetamine derivatives.
“Although the so-called ‘legals’ may contain illegal substances, the police don’t have the resources to undertake a pharmacological analysis of every sachet of powder on sale, especially in Bucharest, where police don’t have enough petrol to drive their cars to solve murder cases,” says Dr Adrian Abagiu, Senior Doctor in Infectious Diseases,
Centre for Integrated Services for Addiction, Matei Bals Hospital.
Sometimes users mix legal highs with heroin or methadone. “People on methadone, when they use legals like mephedrone, combine stimulants and opiates and are more likely to get addicted because of the speedball effect,” says Abagiu. “Combining a legal high with methadone is the speedball of the poor.”
In Bucharest, legal high users have experienced extreme paranoia and epilepsy, while injecting legal highs for only three months can lead users to develop endocarditis – an inflammation of the inner layer of the heart which can dismantle the cardiac valves, leading to a stroke or cardiac arrest.
Bucharest’s Matei Bals hospital used to see around 10 to 20 annual cases of endocarditis, but in 2011 this rose to over 50. Known legal users accounted for 90 per cent of these cases. “In the last six months of 2011 we saw seven deaths among our clients who we know were using legals with methadone and benzodiazepines,” says Abagiu. “These were strokes, one cardiac arrest and two overdoses. The forensic reports show methadone and benzodiazepines in the victims’ bloodstream, but not legals, because we do not have the resources to test for legal highs.”
Not all users want to continue taking legal highs. “Many want to go back to heroin because they become violent and paranoid,” says Marian Ursan. “They lose weight and they don’t sleep.”
Cristi and Gheorghe would return to shooting heroin if the drug’s purity was better and the price was affordable. “If you don’t eat or don’t drink, you don’t sleep and you shoot legals non-stop, you can end up in hospital,” says Gheorghe.
Many others though, prefer legal highs because they can shoot up in the streets without fear of prosecution. In Romania, possession of any quantity of drugs can result in a five-year prison sentence, so this legitimacy gives the users a sense of protection.
“I like to buy from the store,” says Gheorghe. “It means that if the police try to pick me up for injecting, I can show them the receipt.”

Users names have been changed for this article.

The picture shows the Carusel drop-in centre in Ferentari, Bucharest.

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