An all-time high

If one thing appalls foreign health officials and activists more than anything else about Moscow’s response to its heroin problem, it’s the ban on methadone. The World Health Organisation regards methadone as essential in combating heroin dependence, but in Russia anyone caught using it or distributing it can face up to 20 years in prison – as harsh a sentence as that for heroin.

Called a replacement drug, methadone is taken by mouth – so reduces the risk of HIV infection by using shared needles – and is used around the world to treat opiate addiction. Russia is one of just three countries in Eastern Europe and Central Asia to ban the drug, alongside Turkmenistan and Uzbekistan, where heroin consumption is relatively low. China, which has over one million registered heroin addicts, with unofficial estimates running several times over that, has more than 680 methadone sites.

Methadone is a potent synthetic opiate in its own right, but it can eliminate the agonising withdrawal symptoms that addicts experience when they quit heroin. Its main advantages are that it has to come from a healthcare source, in controlled doses and without needles. That gives addicts some chance, over months or sometimes years, to go clean for good.

In Tver, Yuri Ivanov, a doctor and the deputy head of the state-run Tver Regional Narcology Clinic, is dumbfounded by the ban. “Why do civil servants limit me from doing my work?” he asks in his dimly lit office in the crumbling grey clinic, which sits off an unpaved muddy lane in the centre of the city. “All that they are trying to do is the opposite of what we need. It is hard for me to understand… The situation is going backward. When there is no real medicine, they go right back to drugs.”

Ivanov sometimes resorts to giving his patients tropicamide, a drug used by eye surgeons to dilate the pupils and which has a similar effect to heroin. Addicts talk of their rare encounters with methadone users with a sense of wonder and even magic. “All of us know about this drug methadone and all of us want it. People come through who have done it and we can instantly see how much brighter and better they live,” says Tver addict Valera in jittery sentences, high after shooting up twice by midday, in an interview in the back of his tobacco-stained car.

But Moscow won’t be swayed. “The medicine has become more dangerous than the illness. It would be replacing one evil with another,” said the anti-drugs baron Ivanov. “And why on earth would we do that?” Gennady Onischenko, the country’s top doctor, repeatedly dismisses methadone as “still a narcotic”.
In a major government anti-drug strategy launched last June, there was no mention of substitution therapy, even though Moscow says it is now focused on reducing the demand for drugs.

That means that Russia’s measly four federal and 77 regional rehabilitation centres will continue to treat addicts with basic psychotherapy, counseling or simple, traditional painkillers.

The vacuum created by the lack of effective substitution therapies was highlighted in an incident last October in the Ural Mountains town of Nizhny Tagil. Anti-drugs activist Yegor Bychkov, 23, was sentenced to three and a half years in prison for kidnapping drug addicts. Bychkov said he had received permission from the addicts’ parents to forcibly take their sons and chain them to steel bed frames while they underwent a painful detox. Anti-drugs chief Ivanov praised Bychkov, saying he had acted in good will; the head of the parliamentary health committee Olga Borzova said the state was to blame for his arrest as he had become very desperate.

The global fight
The Russian Orthodox Church  also weighed in. Though its official stance is against sex education and regards heroin use as a sin, it has set up rehabilitation centres which offer religious guidance. The church also holds discussions with the UN over the HIV/AIDS crisis.

Unfortunately, those sorts of initiatives may be risky. Almost two years ago, the General Prosecutor’s Office was ordered by Russia’s Security Council to beef up prosecutorial measures against non-governmental organisations which advocate substitution therapy. Since then, activists distributing free needles have been detained on charges of aiding illegal drug use.

“Russian government officials consistently promote falsehoods about harm reduction, and deter those who speak in favour of them,” the IHRA’s Rick Lines says. “Speaking honestly about the vast body of evidence supporting the effectiveness of methadone is a dangerous thing to do [in Russia].”

That may be why relations between the UN’s Global Fund to Fight AIDS, Tuberculosis and Malaria – which has been pushing for methadone legalisation – and Russia’s health ministry ruptured at the end of last year. The Global Fund provides the most finance for HIV/AIDS prevention in Russia and granted $351m to Russia for 2004-11. Now $16m of that allocation remains, and is at risk of being cut this year.

Worse, say global health experts and local NGOs, is the health ministry’s decision to scrap the Global Fund’s needle distribution, HIV awareness and medication programmes. “They proved ineffective and we shall not continue them after 2011,” said Alexander Vlasov, the ministry’s spokesman.

In October last year, the health ministry directly accused the Global Fund of making the HIV epidemic worse. “In the regions where these (Global Fund needle) programmes were operating, the spread of HIV infection increased three-fold,” minister Tatyana Golikova told a respected narcology conference.

The fund says it is keeping up a dialogue with the Health Ministry. But global health experts warn that the decision to end the Global Fund’s work in Russia will be catastrophic. “Russia will fall behind and lose the achievements made so far,” warned IAS president Katabira. “We will not be able to recover the situation.”