Life Goes on In Crimea, (unless your on methadone…)

Life Goes On in Russia’s Crimea

Here are the final 2 blogs in the series of 4, from Igor Kuzmenko’s personal blogs of Crimea, in particular, life for those who once lived under Ukraine law and received Opiate Substitution Treatment (OST) such as methadone only to lose their new found stability after the region’s Referendum when the majority voted to go back to Russian governance. This effectively closed the doors for good on OST leaving over 800 people in shock and despair. So what is a person withdrawing from treatment supposed to do? What would you do if your access to methadone or buprenorphine was cut off almost overnight…? Igor gives us a frighteningly honest account of what happened to the OST community in Crimea..Here is part 3 and part 4.

NOTE: Part one and two are a bit further down this blog and the whole series has been reprinted here courtesy of INPUD’s blog and you can also read them in Russian at ENPUD’s website /blog. Thanks to Igor for a fascinating insight into Crimea for the drug using community, and INPUD for reprinting.

 

RIP Crimean OST Program, 2006

small_igor (1)

Igor Kuzmenko

Part 3

Meanwhile life in the Crimea went on. As spring approached, people continued to go to work, and students proceeded to attend their studies. Very few inhabitants of the Crimea understood that 806 people of the region’s  population, were literally on the way out.

 

Death From Abstinence

As I  wrote previously, the first patient in Simferopol died around the beginning of April. He was about 50, was seriously ill and couldn’t move at all. Everything was good with him before the March events; the doctor wrote a prescription for him so he could get liquid methadone and he continued to use Opiate Substitution Therapy without leaving the apartment. But after March 16, everything changed and the prescription form of OST was suspended in Crimea. It goes without saying that any coroner wouldn’t determine a cause of death as ‘death from abstinency’. But something tells me that if he continued to have the opportunity to receive methadone, he would be still alive.

 

 But after March 16, everything changed and the prescription form of OST was suspended in Crimea.

 

Bupe Not Methadone

Actually,  there were not so many people receiving OST on a prescription basis in the Crimea. And there were a few reasons for that. First,  the prescription form is possible only for those people who receive buprenorphine in Ukraine. There are cities where all clients of the buprenorphine program constantly receive it using a prescription. But everything is much more difficult when dealing with methadone.

ukrainianmethadone

The medicine used in a Ukrainian methadone OST program – known as ‘Metadict’ and ‘Metadole’ – are both made in Germany or Canada. Both of them are in the form of tablets, not syrup. They come in blister packs of 10 tablets: 25 mg each, (total 250mg)  or in bottles of 500 mg. But it is impossible to get it using a prescription because according to the laws of Ukraine a single prescription dose of any narcotic substance mustn’t exceed 112 mg. The blister packs are not allowed to be cut up or tablets prescribed separately from the packaging. There were individual cases when patients could receive a liquid methadone on prescription, but only on a commercial basis and it is very expensive.

 

Methadone Not Bupe

In the Crimea, it is different. Slightly more than 50 people out of 806 patients received buprenorphine, the others got methadone. About 10 people out of those 50 had the opportunity to receive buprenorphine on prescription though not on a constant basis. They got it occasionally – because of a business trip, illness or going on a holiday.

ukrainian-methadone-metadol

Ukrainian methadone; Metadol

 

There is also one more reason for prescriptions being shut down in the Crimea after “the referendum”. Doctors were afraid to write out prescriptions on both of these substances because they are actually illegal in Russia and so employees of drugstores in turn, were afraid to sell the medications and fill  these prescriptions.

 

May 20th – D Day

May 20 was the last day when people could use the OST program in the Crimea, so after that each of the 806 person’s who were prescribed had to make one’s own choices of what to do. There were only four options:

  1. String oneself up to stop using drugs forever
  2. Go to Russian local rehabilitation centers praised by numerous Russian “guests”;
  3. Continue using OST by moving to Ukraine;
  4. Go back to using “street” drugs.

According to my knowledge, no more than 20-30 people went to Russia for rehab. Many of them couldn’t undergo an entire “rehabilitation course” till the end and ran away. However, some stayed in rehab for the whole term. One OST client from Simferopol died in St. Petersburg during the rehabilitation process. He died of an overdose.

Slightly less than 60 people risked going to Ukraine. This option was, undoubtedly, the most realistic of all. For example, in many cases it was necessary to buy tickets at ones’ own expense to go to Russia, but in Ukraine both tickets, accommodation and food were paid for you.

 

Should I Stay or Should I Go?

Nevertheless, as you can see by the number of people who went to Ukraine, it didn’t become a mass phenomenon. Partly, this was due to mass media propaganda which colourfully described the various ‘atrocities’ of Ukrainians in relation to the inhabitants of the Crimea who risked leaving and facing the ‘mockeries’ of the Ukrainian border guards who were taking away passports on the border and other nonsense. The other reason that many of inhabitants of the Crimea never left for Ukraine, was they had neither friends, nor relatives there and simply couldn’t imagine where they were supposed to go.

Now many of the clients of OST who had gone to Ukraine, already found a job there, and all without exception found rented accommodation and received some financial support from the project MBF “Renaissance”.

 

“It turns out that more than 600 people started taking street drugs again.”

 

From those people with whom I was in contact no more than 10 people could finally stop taking drugs of any kind.    If you make simple arithmetic operation, it turns out the following:

806 (total number of clients in the Crimea OST program) minus 20 (number of those who undergone “rehabilitation” in Russia), minus 60 (left to Ukraine), minus 50 (suppose not 10, but 50 people stopped taking drugs) = 676.

About 30 already died out of that number of people. It turns out that more than 600 people started taking street drugs again. And many of them during many years of using the OST program found work, started a family and gave birth to children.  Now it’s all over.

 Igor Kuzmenko

Below is the final part of Igor Kuzmenko’s series on Crimea. Please feel free to add your thoughts and comments and let us know if you have a story to tell from your country.

 RIP Crimean OST Program, 2006

 

Igor Kuzmenko

Igor Kuzmenko

Part 4

How to reach those people who made decisions on the issues of Opiate Substitution Therapy (OST)  in the Crimea? Which words should be found to explain to them that situation where 800 drug users under constant medical and psychological control, employed and reintegrated, is much better than 800 people coming back to being criminalised in the drug trade? How could one explain what the blue sky is to the person born blind? How it is possible to explain to a mother, whose son quietly had been using OST for several years, stopped breaking the law, started a family and found a job, why he has died of an overdose during the rehabilitation? Who benefits from it?

“What we had been created for several years was destroyed in two and a half months.”

Probably, for those people who have nothing to do with OST and don’t have the slightest idea of what this therapy actually is, it is only a “change of the dealer” – earlier I bought drugs on the street and now I get them free of charge from the doctor. But actually OST is a difficult system in which the process of taking methadone or buprenorphine is only a small part of the whole process. OST is a complex of actions that allow the person to live a more or less productive life. Many elements of this scheme, such as the ART (Anti Retroviral Therapy*), anti-tubercular therapy, are strongly connected with OST. There is no point in pretending otherwise, many people started to use ART and to look after their health only after they visited the OST site.

 

Irina, a client from the OST program

Irina, a client from the OST program


Stability and the Street

What we had been created for several years was destroyed in two and a half months.

So, more than 600 former people from the OST programs have taken part in the illicit drug scene again since May. What do our people use to medicate themselves with now?

Lyrica. This beautiful and romantic word is actually the name for one of the biggest problems of the Crimean drug scene nowadays. Lyrica (active agent – Pregabalin). An antiepileptic and anticonvulsive medical product made by Pfizer Company. Many ex-OST patients are suffering from its over-use today. It has excellent medical qualities if you take it on prescription, but it causes terrible side effects and dependence for those people who try to combat withdrawal syndrome with its help. It is sold freely in any drugstore in the Crimea and costs not so much.

Only a total deficiency of any medical products in local drugstores is saving others from the serious consequences of pharmaceutical drug dependence in the Crimea.

“Now I hear from people who were full of vim and vigor, who had plans for the future just two months ago, that they want to die.”

Checks. “Checks” is how people name portions of raw opium from which it is possible to extract heroin, if you add acetic anhydride to it.

“Checks” existed in the Crimea as far back as I can remember. It is a good reliable way to quickly recover from withdrawal syndrome. You could get “checks” quite easily at any time. But after the OST programs were closed, hundreds of drug users suddenly entered the market (more than 200 people just in Simferopol! ) and devastated all the opium reserves in the Crimea. Moreover, new anti-narcotic structures represented by the Russian police (all police officers came to the Crimea from the Russian cities – Perm, Kazan, Moscow, there are not any local representatives in police) and by Federal Service on Control of the Drug trafficking (FDCS) – the nightmare of the Russian drug users. The increase in number of “checks” users led to a decrease in its supply and importing from Ukraine became a big problem.

By hearsay, so as not to suddenly miss an opportunity to increase profits, dealers began to add foreign substances to their product, it could be harmless substances or hard shit like home-made methadone. New police forces and new circumstances around buying drugs has led to the situation where purchasing “checks” poses a big problem now.

Heroin. I often hear from people in the Crimea that there is lot of cheap heroin here now. But I couldn’t find even one person who saw or tried that heroin. So I can draw a conclusion that there is not and there was not any heroin in the Crimea.

Krokodil. I assure you that if it wasn’t for a deficiency of medical products in drugstores, including codeine-containing ones, “krokodil” would now be problem No. 1 in the Crimea. But every cloud has a silver lining.  People just can’t find the substance that you should use to make this poison, and that’s why krokodil isn’t present in the Crimean drug scene.

“Well, this is how it goes.”

Well, this is how it goes.

Now I hear from people who were full of vim and vigor, who had plans for the future just two months ago that they want to die. Former patients aren’t able to go to work because they suffer from never-ending withdrawal syndrome. Their families suffer as much as they do.

I am an optimist.  My glass is always half full. But I can’t see anything optimistic in the future of those from the last OST programme in Crimea.

Well, who knows, maybe I’m mistaken.

Written by Igor Kuzmenko

*ART: Anti Retroviral Therapy is a medical treatment for HIV/AIDS

 

All 4 parts in the Crimean OST series has been written by Igor Kuzmenko and here’s a massive public thank you to him for his really honest and personal insights into what it has been like for our peers in the region, and answering many of our questions too, I’m sure. The blogs were translated from Russian into English by the very professional Daria Mighty, and we are indebted to her speed and accuracy, thank you Daria! (The Russian version is available atENPUD)
If you want to find out more about the drug using community and its issues in the region of Eurasia, or you are living in that part of the world, check out INPUD’s sister organisation on their website ENPUD (The Eurasian Network of People who Use Drugs). You can become a member, read other blogs from Igor and others and find out the news and views on drug issues and politics.

Dec 1st Russian Embassy Protest -Be there!

The Red ribbon is a symbol for solidarity with...

WORLD AIDS DAY

On Dec 1st, 2011, World Aids day, people in 8 countries around the world will descend on Russian Embassies -To protest at the criminal treatment of people who use drugs – in the biggest catastrophe in the history of HIV in recent times. (See below for where and when).

In Russia today, we are bearing witness to one of the biggest, avoidable catastrophes in the history of HIV – the lack of response to the epidemic in Russia. We must point directly to the specific responsibility that Russian medical and public health officials bear for creating and sustaining this disastrous situation. Of particular concern are Russia’s, brutalising drug policies and its recently revised Total War on Drugs, which has resulted in further pushing people who use drugs into hiding, prison, and enforced detention, and severely compromising efforts from the international community to revert the trajectory of HIV/AIDS. The world is approaching a crossroads; a strong and decisive downward trajectory in the epidemic is possible in all countries -but it will only happen if the people who are most vulnerable to infection are supported and their human rights realised. Governments have legal obligations to act. Indeed, the implementation of harm reduction measures is consistant with and required by states obligations under international human rights law. 1,2.

Injecting drugs with contaminated equipment is driving Russia’s HIV epidemic, now the fastest growing in the world and it is reflected in the numbers; as many as 80% of new infections are occurring amongst people who inject drugs (PWID), in a total HIV positive population of approx 1million. With this in mind, recent projections forecast an additional 5 million people could become infected with HIV in the near future, unless Russia transforms the way it is dealing with its HIV pandemic.6

Russian authorities have repeatedly come in for fierce international criticism over their policy towards the treatment of drug dependence, which relies almost completely on the promotion of abstinence to the exclusion of harm reduction.  Russian officials claim, incorrectly, that the effectiveness of opiate substitution therapy (such as providing methadone and buprenorphine) has not been adequately demonstrated, and as such it is prohibited by law. Yet, despite the addition in 2005 of these two drugs to WHO’s list of essential medicines, and multiple position papers by international experts calling for substitution treatment as a critical element in the response to HIV (IOM, 2006; UNODC, UNAIDS, and WHO, 2005), methadone or buprenorphine remain prohibited by law in Russia and promotion of its use – punishable by a jail sentence.
Compare this legitimate injection kit obtained...

Sterile needles and syringes are proven ways to prevent the spread of HIV

With over 30,000 people dying from drug overdoses every year, numbers that can be shown to markedly reduce with the implementation of OST, and 150 becoming infected with HIV each day (2/3rds of which are injecting drug users), also evidenced to drastically reduce with the roll out of Needle and Syringe Programmes (NSP), it is upon everyone who cares about humanity, to demand an immediate transformational shift in Russia’s approach to HIV prevention and its treatment of drug users.  Access to NSP and OST is in itself, a human right;  UN Ruman Rights Monitors have specifically stated harm reduction interventions as necessary for states to comply with the right to health. 5)

Consistent evidence from around the world shows that treatment for opiate dependence works most effectively when the exclusive goal of abstinence is widened to foster multiple outcomes – including reduction in use of illicit opiates, exposures to blood-borne infections such as HIV and hepatitis, reduction in drug overdoses, better management of existing health problems etc. Evidence has repeatedly shown the clear benefits to the individual and society as a whole when drug dependence is viewed as a public health issue, as opposed to a criminal one. Evidence also shows OST, combined with a range of harm reduction measures such NSP, leads to a drastic reduction in the spread of new HIV infections in countries across the globe; none of this more clearly demonstrated today, than in Netherlands, a world leader in harm reduction where in 2010, only ONE injecting drug user contracted HIV. In the UK, another country that has harm reduction at the centre of its HIV prevention strategy, prevalence of HIV amongst drug injectors is at 1.5%, this against a Russian HIV prevalence backdrop of 30-35%. The evidence on harm reduction has been in for years. Why does Russia continue to turn its back?
The Russian government‘s estimated annual expenditure related to drug law enforcement) equal approx 100 million US  dollars. 7. This amount does not include the money spent on detention and imprisonment. In stark comparison, only 20 million US dollars was allocated to HIV and hepatitis B and C  prevention combined, among all population groups in 2011. By 2013, amounts spent will be three times less. Considering the context and tendencies in the development of the HIV epidemic in Russia, clearly such policies are not leading to any positive results. No money at all is allocated towards HIV prevention among the injecting drug using population.6Such punitive and torturous approaches to tackling drug use are not only fuelling the HIV epidemic in the region, but also the stigma, hate and ignorance of drugs, and of people who use drugs.  The insistence by both the Russian government and medical profession to treat drug users as criminals that need imprisonment at worst, and at best – enforced detention, has meant harm-reduction programs, including needle exchange, are officially accused of propagandizing drug use and activists have been arrested, harrassed and imprisoned for promoting harm reduction measures. Demonstrators who have protested and spoken out against the Russian response to HIV/AIDS are also regularly arrested and detained, including HIV positive people calling for access to ARV’s (drugs to treat HIV) and an end to treatment interruption fuelling drug resistant strains of HIV.This World Aids Day, December 1st 2011, we will echo the urgent voices of Russian drug users who are living and dying in the grip of an HIV and TB pandemic with almost no recourse or chance to engage in or promote an effective response.  . We will gather at Russian embassies around the world to demand Russia to change it current course towards death and disease. We want to see inappropriately aggressive, state sponsored hostility to drug users replaced by enlightened, scientifically driven attitudes and more equitable societal responses” 3 We demand our own countries to apply pressure wherever and whenever they can, voicing publicly our concerns about human rights abuses in the Russian response to drug use and HIV.
Sound, evidenced based and cost effective harm reduction solutions stand at the forefront of what has been shown to effectively prevent HIV infection in the drug using community. The personal narratives of people who use drugs and their allies on the front line of human right struggles must be recognised and remain a key part of today’s growing evidence base. People who use drugs must be seen as central players in the search for solutions rather than being framed and targeted as the problem.
Nothing About Us Without Us  www.inpud.net
Dec 1st at Russian Embassies in London, Stockholm, Berlin, Bucharest, New York, Sydney/Canberra, Spain (?), and Toronto. Dec 1st
 for times and locations follow updates at http://russianembassyprotest.wordpress.com or (add your email/website)

1) UNIDCP Flexibility of Treaty positions as regards harm redcution approaches, decision 74/10 Geneva UN 2002 ,
2) UNODC World Drug Report Vienna 2009
3) Lancet July 2010 HIV in people who use Drugs
4) The right to the highest attainable standard of health; Article 12, comment 14  International Covenent on  Economic, Cultural and Social Rights 2000
5) Barrett D et al;  Harm Reduction and Human Rights, the Global response to drug related HIV Epidemics. London, HRI, 2009
6) News Release, Oct 7th 2011, Risk of HIV Hitting Catastrophic Levels; from the Canadian HIV/AIDS Legal Network; Eurasian Harm Reduction Network; Harm Reduction International;
7) Articles 228-233 of the Russian Criminal Code

A young Russian and a message you can’t forget.

The Red ribbon is a symbol for solidarity with...

Russia’s Aleksey Kurmanaevskiy speech delivered at the UN High Level Meeting on HIV and AIDS in New York – June 9 2011 by INPUD on Thursday, 09 June 2011 at 18:33:

INPUD is a global peer-based organisation that seeks to promote the health and defend the rights of people who use drugs. We will expose and challenge stigma, discrimination and the criminalisation of people who use drugs and its impact on our community’s health and rights. We will achieve this through processes of empowerment and international advocacy. Find us at: http://www.inpud.net, Facebook/INPUD, Twitter/INPUD. Blog at: http://www.inpud.wordpress.comThe following speech was delivered by Aleksey Kurmanaevskiy at A dialogue on HIV and Human Rights at: Universal Access for Key Affected Populations. This event was hosted by the United Kingdom and the Republic of South Africa together with the International HIV/AIDS Alliance and the International Federation of the Red Cross and Red Crescent Societies. This session took place at the High Level Meeting on HIV and AIDS at the United Nations in New York City.

Aleksey is from Russia and is 30 years old. He has been dependent on drugs for 15 years, and has been living with HIV for 11 years. He is a member of the International Network of People who Use Drugs (INPUD) and will speak with you today for people who inject drugs, those who are living with HIV\AIDS, and for the members of the drug using community who are no longer with us because of HIV\AIDS, Tuberculosis, Hepatitis, and drug Overdoses.

Text of Aleksey’s speech:

Q1 – Highlight key challenge or obstacle & successful action or approach:

I would like to call to attention the laws and practices that are based on the criminalization of people who use drugs and the consequences of these measures. In our opinion, the practice of imprisoning people who use drugs in order to deny them their freedom or subjecting them to coerced treatment for the personal use of drugs should be ended. Imprisonment and coerced treatment are clear breaches of human rights that undermine the public health of people who use drugs and the wider community.

The criminalisation of people who use drugs and the widespread stigma and discrimination against our community results in people hiding and living in fear and secrecy. This can cut people off from family support and drives people further into problem drug use. As such, punitive laws can dramatically reduce the effectiveness of HIV prevention strategies with my community and undermine access to and retention in services. As a result, punitive laws are costly and ineffective.

The introduction of science-based harm reduction interventions like needle and syringe programmes, opioid substitution therapy (OST), and overdose management programmes is saving the lives of my community in many countries in the world. We have the experience, the evidence and tools to end concentrated epidemics of HIV among people who inject drugs. 30 years of evidence demonstrates that OST radically improves the health and wellbeing of people who take drugs and supports our engagement in HIV and TB treatment. Significantly OST gives people who are dependent on heroin and other opiate drugs an alternative to crime and allows us to fully participate in and contribute to society. History has shown that when people who use drugs are involved in the design, development and delivery of HIV prevention interventions, the reach is greater, the quality is higher and there is better value for money.

Q2 – 1 or 2 key recommendations to HLM on practical way forward:

I am a husband and father of two sons and very much want peace and mutual understanding within my family. I learned that it is absolutely critical to listen to my loved ones. Before agreeing on a solution, we consider all of the possible alternatives. The very welfare of our family depends upon this process of open dialogue.

I have drawn this analogy deliberately. The family can be viewed as a microcosm of society. We are all members of one global family. Though we all have unique worldviews, customs, and ways of life, there is no doubt that we have to deal with the HIV epidemic together. The foundation of such mutual understanding through dialogue is the first step in this process.

Around the world people who inject drugs are giving sterile injecting equipment to their friends, are sharing education and knowledge and supporting service access. At a global and regional level drug user organisations are supporting consultation and contributing to policy development. At a country level we can provide a community watch dog function helping donors to spend money wisely and programmers to deliver services effectively.

Our challenge to all countries is meaningfully involve people who use drugs in the design, implementation and monitoring of the HIV response. If you are serious about engaging us as true partners then this has include the resourcing of our organisations and the meaningful participation of our representatives. This is key to reversing the trajectory of the HIV epidemic and bringing under control the spiraling costs of HIV. It is time to stop framing my community always as the problem and instead to recognise that we are a key part of the solution to HIV.

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