“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 Kiev late in 2014.
Eloquent, educated and talkative, the mid-sized 28-year-old sound technician was a little disheveled, with long hair, stubble and a thick woolen 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 Medication-Assisted Treatment (MAT) 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 MAT opioids methadone and buprenorphine.
Along with more than 800 other Crimean MAT clients, Ivan faced three choices: Leave, detox or risk relapsing into crime and fatal addiction.
How Ivan’s problems began
Ivan did not choose to become addicted. 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” synthesized 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 paralyzed, 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 MAT 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.”
MAT: a bridge to society
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 (Kiev).
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 centers also gave counseling and medical tests and were a vital link between an underground culture and public health.
Here, users talked, played chess, socialized, 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 people who use drugs to 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.
Russia imposes a swift shut-down
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-favored President Victor Yanukovich, Vladimir Putin’s forces and sympathizers annexed Crimea—a region that had been traditionally more pro-Russian and that hosts Russia’s Black Sea fleet.
Russia banned Medication-Assisted Treatment in 1998, and the new authorities in Crimea gave all MAT 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 MAT 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 organizing MAT supply of “representing the interests of Western pharmaceutical companies.”
Ivanov attacked the civil society members who were complaining about the MAT shut-down, 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.
MAT 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 MAT 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 MAT 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, disabled people, pensioners and parents of teenage boys, many of whom were suffering from HIV, tuberculosis and hepatitis.
A couple, sitting in a park with a newborn baby playing in their laps, pleaded, “If we close the program, the happiness we built up over several years will be broken down.”
Each person 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 program to continue. The users had three options: Revert to street drugs, flee to mainland Ukraine to continue therapy or detox in Russia.
Russia offers anything but MAT
In Russia’s state-run rehabilitation centers, 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.
In the 1970s and 1980s, the USSR used similar drugs against dissidents as part of a “repressive psychiatry” program 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 centers 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 fetal 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 Center estimates that Russia will register more than one million infections in 2015. Of even greater concern is the Center’s prediction that this could double in two years to two million. From this figure, 60% 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 “generalized” 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 MAT 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 MAT],” 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 MAT, they overdose—much like someone dependent on alcohol who has been abstinent for three years believes he can still neck a liter of vodka.
Fifty-year-old Andrei also pleads for life in the video. A squat man with a mustache and a flat cap, he resembles a typical Soviet public servant.
The Center, 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 MAT clients, 20 people have died.
As well as suicide and overdose, some died from complications related to HIV and tuberculosis. Because the users were no longer accessing medical services to receive MAT, they stopped getting vital medication to suppress these viruses.
It is now estimated up to 100 of Crimea’s 803 OST patients are dead.
Ivan becomes a refugee
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 Kiev-based Alliance for Public Health was offering MAT patients from Crimea and the Russian-backed rebel region of Donbas the chance to stay in a hostel in mainland Ukraine and receive MAT 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 Kiev 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.”
“Kiev is the first place in life I can feel complete freedom. It feels good in Kiev. People are quite kind, and there are no serious acts of aggression or intolerance.”
One year later, I wanted 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 MAT. He lives drug-free, has a girlfriend and is building and selling top-end amplifiers.
*Name has been changed.
This piece was first published by New Zealand Drug Foundation—an NGO promoting healthy approaches to all drugs—in its regular magazine, Matters of Substance. You can follow New Zealand Drug Foundation on Twitter: @NZDrug.
The featured image shows Igor, a drug user in Crimea who is not mentioned in this piece: source.