Rapid Policy Assessment and Response

1

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
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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) 1Source S.
  Matic, J. V. Lazarus, M.C. Donoghoe HIV/AIDS in
  Europe Moving from death sentence to chronic
  disease management, WHO/Europe 2006

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Homemade Amphetamines have a long history in
Eastern Europe

• 1980s 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
• 1980s Users began making Vint a homemade
  preparation containing methamphetamine and
  obtained via ephedrine reduction
• 1990s Users began making Boltushka using a less
  complicated process. Boltushka is homemade
  preparation containing methcathinone.
  Pseudoephedrine-containing cold medications
  oxidized with KMnO4 produce Boltushka.
• 1990s 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.

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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).
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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.

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

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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)

9
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.

10
Boltushka and its use

• Cost per dose - ltUS1.00
• 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)

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Boltushka and its use

• needles and syringes are the last thing to worry
  about you need to find money for pills thats
  whats important. In most cases after having gone
  a long way to buy the pills and hurrying back
  home to make boltushka you dont even remember to
  think about syringes. Theres at least one person
  in the group who will have the syringe if you
  dont have yours1.
• 1 Ukraine/Odessa/Interview 4 with IDU/RPAR
  Project/January 2006 (UKR/IDU/4)

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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.

13
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 bribes1.
• 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)

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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

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Reported behavioral effects of boltushka use

• High level of activity and energy
• Talkativeness
• Reported loss of appetite for 2-3 days.

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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 drugs other effects