Up to 100 users of opioid substitution therapy drugs have died in Crimea since Russia seized the Ukrainian peninsula in 2014 and banned their medication. Michael Bird reports on the dire consequences of Russia’s harsh anti-drugs crusade.
I had to abandon home, family and friends to a place where nobody was waiting for me.” Former injectable drug user Ivan spoke to me in Ukraine’s capital of Kyiv late in 2014.
Eloquent, educated and talkative, the mid-sized 28-year-old sound technician was a little dishevelled with long hair, stubble and a thick woollen jumper. He resembled a roadie for a 90s Americana rock band and admitted he was open – almost too open – to speaking about his addiction.
“I can talk someone to death if given the chance,” he said.
Until spring 2014, Ivan lived in Crimea, where he was taking the opioid substitution therapy (OST) drug buprenorphine. This medication regulated his life, helped him hold down a job and broke his link to a damaging lifestyle of injecting narcotics and stimulants up to 15 times per day.
But when the Russians seized the peninsula in March 2014, the new leadership banned the supply of OST opiates methadone and buprenorphine. Along with more than 800 other Crimean OST clients, Ivan faced three choices: leave, detox or risk relapsing into crime and fatal addiction.
Ivan did not choose to become an addict. It started when he was 15 years old in 2001. After a serious bike accident that left his leg injured, doctors tanked him up on narcotic like pain reliever tramadol. When he left hospital, he was handed 10 packs of the drug, which he shared with his friends.
“After the accident, I realised I wanted to live. I drank and had parties and enjoyed life to the full.”
But he wanted to escape from the tramadol, and soon he was injecting a home-made stimulant called vint – a meth-like concoction using the ephedrine extracted from cold and flu tablets. Users told him he could get off tramadol by getting high on vint instead.
Then Ivan tried shirka – a ‘village heroin’ synthesised from the powdered heads of a Ukraine-grown poppy. He would inject at home, in the countryside, under bridges and in bus shelters. He lost half a year to lack of sleep and food and to memory loss. He did not wash and often slept on the street.
Once, after a shot of vint, he felt a tingle, then a spasm and collapsed. It was a stroke. The right side of his body was partially paralysed, and the pupil of one of his eyes fell to the side.
But he did not stop. Now he took anything to relieve the pain – a cocktail of drugs that gave the effect of feeling as though “I was moving on the earth but also swimming in the sea”.
Eventually in 2008, he heard about the availability of OST in the Crimean capital of Simferopol. He entered the local clinic, walked straight into the room of the chief narcologist and told him, “I am told you are a very kind man. Please help me, or I will die.”
In 2013, there were 21,100 injecting drug users in the Crimean peninsula among a population of 2.3 million, according to the NGO Alliance for Public Health (Kyiv).
OST was legal in Crimea from 2006. Eight locations in the major towns and cities offered the service, which was taken up by 806 patients. These centres also gave counselling and medical tests and were a vital link between an underground culture and public health.
Here, users talked, played chess, socialised, celebrated birthdays, married and had kids – even rendezvoused with lovers. But they also took drugs to suppress the effects of HIV, hepatitis and tuberculosis – diseases prevalent among drug users in the ex-Soviet states.
OST gave them a daily routine and connected them to society through a regime that reduced their chances of using hard drugs, sharing needles or contracting HIV.
This option is recommended by the World Health Organization and the United Nations as an instrument in a toolbox of services to help users quit.
“Comprehensive harm-reduction strategies, which include opioid substitution therapy, are essential to prevent and treat HIV, hepatitis and tuberculosis among people who inject drugs everywhere, including in Crimea,” the Secretary- General’s Special Envoy on HIV/AIDS in Eastern Europe and Central Asia Michel Kazatchkine says.
“Harm-reduction strategies give people who inject drugs the best chance of leading a healthy and productive life and will help to reverse the rising number of new HIV infections across Eastern Europe.”
Ivan’s course of buprenorphine took him from under the bridges and out of the bus shelters, and soon he was working as a cargo handler in the nearby port, before finding a job as a sound technician.
But in a near-bloodless coup in March 2014, the Russians seized Crimea. Moscow was reacting to what it perceived was western-backed interference in Ukraine’s democracy. After the fall of the Kremlin favoured President Victor Yanukovych, Vladimir Putin’s forces and sympathisers annexed Crimea – a region that had been traditionally more pro-Russian and that hosts Russia’s Black Sea fleet.
Russia banned opiate substitution treatment in 1998, and the new authorities in Crimea gave all OST providers less than a month to close operations. In April 2014, the head of Russia’s Federal Drug Control Service, Victor Ivanov, visited Crimea to impose the new policy.
He framed OST as part of a corrupt western attempt to infiltrate Russia’s right to decide its own health policy. In a speech, he denounced the NGOs involved in organising OST supply of “representing the interests of western pharmaceutical companies”.
Ivanov attacked the civil society members who were complaining about the OST shutdown, claiming they were “provoking anti-Russian protests among consumers of methadone and their relatives” because they were afraid of losing foreign financing.
The drug that had regulated Ivan’s life vanished.
Users were scared that a sudden break in their regime could kill them. They also wanted to show the new leadership that their choice of using OST was not part of a political game to discredit Russian health policy.
In May 2014, Crimean drug activist Igor Kouzmenko filmed drug users imploring Russia to allow them to continue their OST regime. Ten users braved public exposure to state their case for a humane intervention by Moscow. These included a former ‘liquidator’ who helped clean up radioactive waste from the Chernobyl nuclear power station, invalids, pensioners and parents of teenage boys, many of whom were suffering from HIV, tuberculosis and hepatitis.
A couple, sitting in a park with a new-born baby playing in their laps, pleaded, “If we close the programme, the happiness we built up over several years will be broken down.”
Each of the users spoke to the camera without anger or despair, stating, “Please do not let us die.”
Kouzmenko’s video ended with the words, “They do not talk about politics. They do not ask for much. They just want to live.”
But the authorities did not allow the programme to continue. The users had three options: revert to street drugs, flee to mainland Ukraine to continue therapy or detox in Russia.
In Russia’s state-run rehabilitation centres, addiction is seen as a psychiatric issue. Medicines given to patients include benzodiazepines, barbiturates, neuroleptics and anti-psychotic drugs such as haloperidol, used in the past to treat schizophrenia.
Man, woman and baby - A Russian family pleads with the government to let them continue their OST regime.
In the 1970s and 1980s, the USSR used similar drugs against dissidents as part of a “repressive psychiatry” programme to silence internal opposition and frame critics of the Soviet Union as mentally defective.
“Now, they are using the same drugs to treat drug addicts,” says Anya Sarang, President of Russia-based NGO the Andrey Rylkov Foundation.
In Russia, there are also private rehabilitation centres that can use “approved” methods to treat drug users. These patented techniques include prayer, hitting a patient’s head with a bolt of lightning, electrodes in the ears, shock treatment, telling the patient to imagine entering God’s temple and swearing to give up drugs, charms to be spoken on Tuesdays and Thursdays for men and on Wednesdays and Fridays for women, heating the body to 43 degrees, inducing a coma and implanting the foetal brain tissue from a guinea pig below the patient’s cranium to reduce the side effects of treatment and abstinence.
Spanking therapy is also on offer for people fighting an addiction. Used as a cure against alcoholism, depression and obesity, a healer smashes a fistful of thick and heavy branches against a patient’s back until the skin bruises. These methods are all available, but methadone is banned.
“The rehabilitation and abstinence-based approach is viewed and presented in Russia as an alternative – or in opposition to substitution treatment,” says Anya Sarang. “But shouldn’t there be many options for [users] to get what they want; to see what would be most helpful for them?”
Russia is experiencing a massive rise in HIV. The Russian Federal AIDS Centre estimates that Russia will register more than one million infections in 2015. Of even greater concern is the Centre’s prediction that this could double in two years to two million. From this figure, 60 percent are injecting drug users.
However, the real number of HIV carriers could be between one and four million people from a population of 146.5 million. Therefore, Russia risks crossing from hosting a ‘concentrated’ to a ‘generalised’ epidemic.
“The lack of substitution treatment is one of the reasons why Russia has not been able to control the HIV epidemic,” says Sarang.
Drug users with HIV are more likely to adhere to a regime of anti-retrovirals if they receive OST treatment for their addiction at the same time – and ideally at the same place.
Also worrying is tuberculosis, which is on the rise in Russia and is the main cause of death among people with HIV. Recent research from 13 Russian tuberculosis hospitals by the Andrey Rylkov Foundation found that the rate of drug-dependent patients who dropped out of treatment veered between 70 and 100 percent.
More than 120,000 are also in prison in Russia for drug-related crimes – a massive increase since 2005. Jails themselves become not only a school for crime but a hotbed of addiction and disease.
“There are a whole bunch of issues which could be solved if we had this simple intervention [of OST],” says Sarang. “It’s really cheap and cost-effective. If we had that, we could solve all the problems in the medical, law enforcement and criminal fields.”
In the video of Crimean drug users is Anton, in his late 30s, dressed in a hoodie with a wan and pockmarked face and a leg disabled from injecting home-made drugs.
When the Russians took over, Anton went to a rehab clinic in St Petersburg. However, he did not receive the detox he expected. Methadone creates its own dependency, and the doctors were unsure how to tackle the side effects of abstinence from it. Anton reverted to using street drugs and died of an overdose.
Without methadone, users can relapse into taking heroin, and because their body is not conditioned to absorb the drug in the quantity they consumed before going on OST, they overdose – much like someone dependent on alcohol who has been abstinent for three years believes he can still neck a litre of vodka.
Fifty-year-old Andrei also pleads for life in the video. A squat man with a moustache and a flat cap, he resembles a typical Soviet public servant.
The Centre, says Igor Kouzmenko, offered Andrei a home and a family. Shortly after the film was made, he killed himself.
By December 2014, the Simferopol community of ex-users was scattered across a continent. I caught up with Kouzmenko, who tells me that, since the video was made, in Simferopol, which serviced 200 OST clients, 20 people have died.
As well as suicide and overdosing, some died from complications related to HIV and tuberculosis. Because the users were no longer accessing medical services to receive OST, they stopped getting vital medication to suppress these viruses.
It is now estimated up to 100 of Crimea’s 803 OST patients are dead.
Meanwhile, Ivan became involved in protesting for the right to his medication. At a public demonstration in front of the Ministry of Health building in Crimea, he found out that the Kyiv-based Alliance for Public Health was offering OST patients from Crimea and the Russian backed rebel region of Donbas the chance to stay in a hostel in mainland Ukraine and receive OST medication – a project supported by the Global Fund. Meals and career advice were available to the users, half of whom had HIV. Many lost their documents because they were running for their lives.
This was a class of “methadone refugees”. In summer 2014, Ivan moved to a hostel in Kyiv and worked as a cashier in a supermarket, playing his guitar and singing in his spare time. In the hostel, he put on concerts for audiences of 40.
Ivan sang me a few lines. In a strong tenor voice, he began an a cappella version of the opening lyrics of a Depeche Mode song, which rise high in the first phrase and then dip low in the second: “Words like violence,” he sang, “break the silence.”
Music was indispensable from his life “like a hand or an ear”, he said. His ambition was “to have a good job and a good family”.
“Kyiv is the first place in life I can feel complete freedom. It feels good in Kyiv. People are quite kind, and there are no serious acts of aggression or intolerance.”
One year later, I want to find out what has happened to Ivan.
In January 2016, from the 60 ‘refugees’ who made it to mainland Ukraine, seven remain in Kyiv and three in the large southern city of Dnipropetrovsk. The remainder returned to Crimea, due to their strong links to the territory. It was tough for them to make a new life.
But I discover Ivan is still on OST. He lives drug-free, has a girlfriend and is building and selling top-end amplifiers.
Ivan’s name has been changed.
Michael Bird lives in Bucharest where he edits theblacksea.eu
Learn more about what is happening in Crimea from the Eurasian Network of People Who Use Drugs (ENPUD) (video).
Survey participants also reported that barriers to accessing services, resources and information were high.
A group of powerful synthetic opioids that were first detected in the country just a year ago may have already been linked to several deaths.
95% of respondents reported positive effects, in a study that looked at both prescription and black market cannabis use.