Fears over future of opioid substitution therapy in Crimea
Russias annexation of Crimea is threatening to force hundreds of people who use drugs back into addiction or turn them into refugees as opioid substitution treatment (OST) programmes in the region seem set to end.
People who inject illicit drugs in Crimea, which, following a controversial March 16 referendum, will become part of Russia possibly within months, have had access to OST in Ukraine for years. Indeed, Ukraines recent reduction of new HIV infections has been put down to the widespread implementation of harm reduction programmes.
But Russian law forbids the provision of OST and organisations working to provide services to people who use drugs in Crimea say there is now a question mark over the fate of the more than 800 people receiving OST in the region. Irina Potapova, coordinator for OST for the International HIV/AIDS Alliance in Ukraine, which runs harm reduction programmes in Crimean cities, tells The Lancet: “In the worst-case scenario, hundreds of patients would be forced to become refugees and seek treatment in mainland Ukraine.”
Russias Federal Drug Control Service (FSKN) has not officially announced plans to put an end to OST after Crimea becomes part of Russia. But Russian media has reported that it is planning to do so and in comments last week FSKN head Viktor Ivanov said he did not recognise OST as a treatment for people who use drugs. The FKSN has also repeated that OST is incompatible with Russian legislation on drugs.
How soon Crimeas legal system can be transformed to meet Russian legislative norms is unclear. Local organisations believe it could be 4 months or more before legislation comes into effect forcing the closure of the programmes.
People on OST in Crimea who spoke to The Lancet said they would struggle to keep down jobs and maintain their health without it, while others said they feared they would return to injection drug use.
The International HIV/AIDS Alliance in Ukraine and partner groups have warned of a major public health risk following any cessation of OST programmes. Andriy Klepikov, executive director of the International HIV/AIDS Alliance in Ukraine, said that hundreds of OST patients suddenly going into withdrawal would “inevitably lead to a drastic increase in both acute illness as well as increases in injecting as people seek to self medicate”.
Those working with people who inject drugs in Crimea say that some have already left Crimea to ensure they could continue receiving OST. Others are actively considering it. 37-year-old Vladimir Vasylenko (name changed), who has been receiving OST in Simferopol since 2008, says: “I am scared, my friends are scared. We dont know what the future holds.”
When asked whether he would eventually be forced to leave Crimea permanently he said he faced a stark choice. “Without substitution therapy, I will die. And that is not me just being dramatic or using a figure of speech, I will literally die. So will many others.”
Accessing treatment centres in Ukraine for many Crimeans receiving OST without leaving the region permanently would be effectively impossible either because of travel costs or distance. But even if it were possible, there are also concerns over whether they would be allowed to even do so by local authorities following repressive Russian policies on drugs. People who inject drugs in Russia face stigmatisation and discrimination in society as well as in many primary health-care facilities. Meanwhile, as well as the OST ban, harm reduction programmes, including needle and syringe exchanges, are very limited and receive little or no central government support. Minor drug offences are punished severely with, for example, convictions for possession of even the smallest amounts of heroin—including residue in a syringe—carrying lengthy jail sentences.
But although it may be months before Crimea becomes part of Russia and adopts Russian drugs legislation officially, OST services could come to a de-facto end within weeks. Since the Russian occupation of the peninsula, supplies of methadone and buprenorphine—two drugs used in OST—have not made it to the region. Roads into the peninsula have been under control of Russian troops and local armed units for weeks. This situation has made supplying the drugs impossible as they can only be transported with an armed Ukrainian police guard. OST centres in Crimea say they have, at most, enough supplies of the drugs to last until mid-April and have already had to begin reducing dosages for OST receivers.
Some patients are already feeling the effects of the lower dosages. One 32-year-old mother of one from Sevastopol, who gave her name only as Ludmila, says: “My dosage has been cut almost in half and its making me really ill. Closing down the OST programmes will be a disaster for me and my entire family.”