Pavel Kutsev taking medication

A week ago Rising Voices published a story about a visit of a delegation from Russia harm reduction activists to Ukraine and methadone site in Kiev. As it was mentioned, a journalist from one of the biggest Russian news paper Moskovskiy Komsomolets, Anastasia Kuzina was a member of the delegation.

After a visit Anastasia wrote a detailed report about the implementation of substitution therapy programs in Ukraine, concluding that such programs could help to stop HIV/AIDS and the TB epidemic in Russia. The leader of Drop-in Center, Pavel Kutsev featured her article.

Here is what Anastasia wrote about the visit on the Methadone site:

10 AM. There is a short line next to entrance of the pharmacology clinic called “Sociotherapy”. I see a poster on the wall in Ukrainian: “Not all people are alcoholics or drug addicts, but all alcoholics and drug addicts are people”. This is “the site” – a place where patients of substitution therapy receive pills of Methadone and Buprenorphine.

There are no very young people in line. Most of them are in their 30's, but there are a few of 40's and older. Each person has a story. There is a person with crutch, a mother holding a small child …

I am entering the site together with Pavel Kutsev. He is a journalist. He is 48 and he is an opiate addict. He and his wife Yanina, the editor-in chief for a newsletter for drug addicts “Motylek” has been in the program for a year and a half.

“Sometimes I hear that substitution therapy is a legalization of drugs” says Pavel. “No, it is the legalization of drug addicts. Addiction is a snowball of problems. Starting substitution therapy you start dealing with them. Later on you can start thinking about givin drugs up completely.”

“What are the most common associations that people have about drugs?” asked Pavel “Everybody would say: death, crime, children without parents, infections, asocial lifestyle. Now let's take a person taking substitute medications. He will not die because of drug overdose. He does not participate in criminal activity. He re-establishes relations with the family. He is able to treat HIV, TB and hepatitis. Moreover, he stops taking drugs intravenously, thus reduces risks of spreading infection. Substitution therapy reduces the most dangerous consequence of the drug addiction.”

A nurse is greeting us. She has to assess the health of the patient, provide the medication, and make sure the patient has taken it (sometimes she crushes the pill with a glass) and make proper records. The nurse is taking three pills from a bottle and, with a piece of folded paper, put them directly to Pavel’s mouth. He is swallowing them up with a bit of water and showing his tongue to the nurse. There is nothing in the mouth. The nurse is nodding and the next person enters the site.

A significant part of Anastasia’s article focused on analyses of whether it would be useful to implement harm reduction programs in Russia. She writes:

In Russia, Methadone is perceived with bewilderment and indignation. But this is because just a few people know how it works.

All over the world there is a category of people with drug addiction which can not be treated by traditional therapy or rehabilitation. Among the reasons are age and the lifestyle of a person. Here I have the statistics on Ukrainian participants of substitution therapy.

Kiev – 55 people, average age – 32, years on drug – 13, all 55 are HIV positive, 53 are positive on hepatitis B and C, 18 have TB.

Odessa – 55 people, average age – 40, years on drugs – 20, HIV positive -38, positive on hepatitis – 20, TB – 12…

With such medical records a person will not be accepted in any rehab program. Substitution therapy is right for them – for people who were rejected by all clinics and hospitals. For 10-20 years they have been living in a circle “to get money – to inject – to get money –to inject”. But “to get money” means to steal, “to inject” means to transfer infections or receive an overdose of drugs…

When a person comes to the program for the first time, doctors select a dose which fits him/her, a dose which allows a normal life rather than looking for street drugs. Taking opiate medication excludes even the possibility of taking street drugs as they just stop working - they do not have any effect any more.

The journalist continues her article with an overview of the situation with substitution therapy in the world. She wrote:

A person has to choose. That is why all over the world the substitution therapy exists together with prevention programs, clinics and rehab centers as well as a group therapy. In many countries only 20 to 40 percent of the drug addicts go for substitution therapy …

Substitution therapy is not just a tool to stop the HIV epidemic; it also helps revive one's own life: get back personal documents, a family, a job; receive a social security and legal assistance. Substitution therapy can be used to increasing motivation in the treatment of HIV and TB. Normally substitution therapy patients have high levels of adherence to the treatment - they do not miss intake of medications and tests.

Anastasia finishes her story quoting a professor from Kazan State University (Russia) and WHO expert Mr. Vladimir Mendelevich. He said:

A drug addict normally pays 30-50 dollars for a drug. While participating in substitution therapy people stop buying drugs thus taking away millions of dollars from the drug market. The cost of the treatment of one patient is $480 a year. That is why a million of people participate in substitution therapy in many countries, including Muslim countries such as Iran and Afghanistan. There are 500 Methadone centers in China alone.

Meeting with the Russian Delegation

A few days ago activists from the harm reduction movement in Russia visited Kiev to learn from their Ukrainian colleagues – leaders from the community of people living with drug addiction, and representatives of the Association of Substitution Therapy Participants. The main event of the meeting was a visit to one of Kiev’s methadone substitution therapy sites. Blogger mimozza described the visit on the Drop-in Center blog.

In Ukraine the government and health care authorities have supported substitution therapy programs as a way of decreasing the spread of HIV, but the Russian government has rejected the public health program, citing a belief that replacing one drug with another can’t be considered medical treatment. For many years Russian harm reduction activists have been fighting for the legalization of methadone programs, but have yet to achieve any noticeable results.   

Mimozza goes on to describeher first impressions of meeting the Russian delegation of substitution therapy activists:

 It seemed that it was a meeting of two separate worlds. One world was one reality, the other was its mirrored reflection. In Russia, even combining the words “harm reduction” is considered to be a crime; something that discredits the dignity of “hard working Russian people”… 

After listening of many horrifying stories from Russia we desperately wanted to show the guests something which is not yet attainable for them – how substitution therapy works in practice. So we took them to the methadone site.

At the beginning the group was not received well on the site. Mimozza explains:

On the metahdone site

 We went to the methadone site on the weekend. Out of all medical personnel there was only one nurse, and many patients. At first the substitution therapy patients in line did not even want to let us in. Our explanation that we wanted to show the site to our guests from Russia did not help. We were totally ignored… So, despite the “ Ukrainians' well-known hospitality”, all twenty of us had to stand in line like everybody else….

 When the delegation finally entered the site, the nurse welcomed them as a delegation from Canada, not Russia. After laughing about this, our guests were able to explore how the methadone site worked.

Mimozza reported:

The nurse seemed to be a bit upset that the guests were not from Canada, but later on she switched into pure Russian and let the representatives of Russian delegation, including a journalist from Moskovskiy Komsomolets see and touch the bottles containing “the mortal drug Methadone” and film everything they wanted.  

The guests were impressed how easy everything works. Just come, receive a few pills and go. Super!

 The only question the Russian guest asked after the visit was why the patients were so aggressive. Mimozza explained:

I had to tell them the whole story of how substitution therapy has been implemented. I explained that the idea of the therapy has as many supporters and opponents. There are only three sites in a city of more than 3 million residents. The police come regularly. Often representatives of media who ask to film on the site and record interviews with the patients end up producing very negative and untruthful stories and videos. That is why the patients are fairly negative toward strangers. After all, it is easy to understand their feelings. They are waiting for their treatment , it is the weekend, they have to stay in a line, and the medication they receive is not the best available ….

But at the same time, every patient is ready to come to the site every single day and it does not matter how far the site is. It is better than waking in the morning with horror and only one thought: where to get money for a dose, what to steal, or what else to sell from home.

Yes, the replacement therapy in Ukraine is developing, but the environment is not easy. We would like to change many aspects of the program and we believe that we will able to do this. We are positive that our Ukrainian harm reduction program will be successful.

 At the end of the post Mimozza gives her advice to Russian friends:

I wish success to my Russian brothers. The main thing is not only to convince the elite that it is impossible to stop HIV/AIDS epidemic with repression toward drug addict and pro-Nazi experiments with sick people, but also to gain a support from ordinary citizens….

Now it is unthinkable to stop spreading inflectional diseases among injection drug users without harm reduction programs that also include syringe exchanges, motivational counseling …

The only reasonable solution is the wide introduction of complex solutions that make up the harm reduction program, of which substitution therapy is a vital element. This way it is possible to stop the epidemics of HIV/AIDS, hepatitis, and tuberculoses, which is growing fast in both of our countries.

The 2nd annual conference of substitution therapy program participants took place at the beginning of October in Dnepropetrovsk, Ukraine. Pavel Kutsev, a director of the organization Drop-In Center, posted a detailed report of the event on his Web blog.

As per tradition, the conference kicked off with a visit to the methadone site so that the delegates could receive their medications. Pavel was impressed by how efficiently things worked at the site, saying:

A bus brought us to a regular municipal clinic, which had a separate entrance for patients of substitution therapy. There was no line at all. A girl with a 3-year-old child entered the methadone office and was out in 3 to 4 minutes. I was wondering whether it was always like this. When my turn came, I also received my medications very quickly and I realized that this is the norm for this site.

Pavel also posted the key points of his presentation at the conference:

Do not keep silent! The main thing for us is not to stay silent. Our voices have already helped accomplish a lot. Look, when we talk about our needs and concerns, even during our meetings, we can support each other. Nobody cares about substitution therapy as much as we do, so we also need to solve our issues ourselves…

…We realized this during our first meeting a year ago and decided to establish an association or a union. During this past year, we have actively worked to implement our plans. We disputed, discussed, negotiated, suggested. And now we have it – the Association of Substitution Therapy Participants…

Pavel also commented on the diversity of people who attended the conference:

When I realized that each region of Ukraine is represented at the conference, I was amazed. Later on I calculated that if one delegate represents hundreds of patients then potentially we have THOUSANDS of supporters. No doubt, we are strong and have a bright future!…

…Today hardly anyone would doubt the power of the association, which might have a 5 digit number of members in the near future. Thus, this association might soon have a very strong influence on the development of Ukrainian drug policy. The main question is, who will control this powerful tool? Do we fully understand our strength? Will we be able to use our consolidation in the right way? I believe the answers to these questions should define the mission of our association.

The conference was attended by a representative from Russia and a few foreign trainers and observers who, in Pavel's opinion, were very professional and knowledgeable. Here's what Pavel wrote about a trainer named Masha Golovanevskaya:

Masha Golovanevskaya not only represented Open Society Institute, but also bought us a fantastic movie, “FIX: The Story of an Addicted City.” The film is about the formation of a world-known organization VANDU, which unites drug addicts from Canada. We started the conference by watching this movie. It was extremely good! We got a copy of it and I promised Masha that I'd do my best to find a way to translate the movie into Russian and post it in our Internet resources so it will be available to everybody.

The second day of the conference was focused on advocacy issues. Pavel Skala, a facilitator of this session, is an expert in drug policy and a former Interpol staff member. Currently he heads the advocacy department of the International HIV/AIDS Alliance. He suggested that participants start creating a list of all the issues that arise in implementing substitution therapy in Ukraine, and then sort the issues based on regional and national problems. Here is what Pavel wrote about this session:

After discussing 16 issues (such as grinding our pills into powder in the hospitals, difficulty in receiving a driver's license, waiting lists for being involved in the program, etc.), we identified three main problems that urgently need our intervention on a national level. They are listed below:

- The continuous process of substitution therapy treatment. Providing the medication every day and even a few times a day when needed;

- Including methadone in the list of medications that are allowed to be purchased by prescription in a drug store. This will improve the effectiveness of substitution therapy and allow people to continue the therapy if they are staying in a hospital where replacement therapy is not provided, or when a person is sick and unable to come to the methadone site.

- Regulating the policy of registering drug addicts and providing patients the opportunity to receive a driver's license on a case by case basis.

That is it! All the other issues were tagged as “local” and solvable at the level of a methadone site or at the regional level.

One question that was discussed was that many medical establishments in Ukraine consider substitution therapy to be a recommendation, not a mandate. This situation was clarified by Dr. Tamara Tretska, deputy director of the Institute of Health Policy Research and the head of the National Substitution Therapy Project. She explained that the Ministry of Health of Ukraine is issuing a new order where substitution therapy is regarded as a “medical practice necessary for the treatment of drug addiction… and use of substitution therapy is mandatory.”

Dr. Tretska's presentation

The third day of the conference was focused on public relations and was facilitated by Nastia Bezverkha, one of the leaders of the youth movement “Obyektyvna realnist,” which unites intellectuals, artists and journalists. Nastia was invited as a media relations trainer and gave a fabulous and informative presentation. In the presentation, Nastia said:

Do you know what the main source of information on drug addiction is? The media

Do you know where the media gets their news? First from the police press service, then from public health workers, then from social workers and only then from drug addicts.

Our voices are only in fourth place, but they should be first!

At the end of the post, Pavel wrote about the main conference outcomes:

After the conference I was looking at my friends and realized that we have become much more confident, full of hope and have future plans.

During the conference we finalized and approved our strategy to develop the association. The conference confirmed our ability to make our own decisions and the independence of our association. The fact that the conference united people from 25 regions of Ukraine proved the unity of like-minded people living with a drug addiction. This is the main element needed to have the capacity to solve issues at the national level.

Until now the war has been limited to banning methadone programs in municipal hospitals of particular cities. But during the past few weeks the anti-methadone campaign has intensified, with new actions such as a press conference against methadone use and police searches of methadone sites. These events were widely reported by Ukrainian mass media and the coverage was not always unbiased.

On September 29 a campaign called “Ukraine without Drugs,” funded by one of the candidates for Ukraine's presidency, held a press conference.

"Ukraine without Drugs" press conference, September 29, Kiev

Pavel attended the event and shared his impressions on the Web blog. He wrote:

The press conference was held in UNIAN facilities [one of the biggest news agencies in Ukraine]. There was not a single person with a medical degree among the organizers. Here are some of the quotations from the press releases:

Ukraine continues methadone experiments! They have already reached our kids in prisons! They want to introduce substitution therapy in prisons! On September 29 activists all over Ukraine are starting a hunger strike in front of government buildings to stop the drug genocide….

This is not the first non-profit to have a repressive attitude towards the issue of drug addiction.

We have tried to involve them in a discussion based on real facts and the truth. For instance, after they stated that “while Europe rejects substitution therapy, Ukraine is importing this trash,” we asked, “Would you mind disclosing the sources of your information?” We got a response saying that “all smart people know this.”

Without presenting a single true fact, without providing a single real figure, these “smart people” attempted to send away all “non-journalists” from the press conference. When I introduced myself as a journalist, a publisher and a patient of substitution therapy, I heard people whispering behind my back that I was not adequate. By the way, most of the people who organized this press conference have been trying to establish a partnership with me and my organization.

I have to say that at least one person, a police officer named Mr. Oleg Shutko, was honest. He admitted that some people vitally need methadone and that the solution to the problem is complex. But even these words were misinterpreted by his colleagues who commented that the number of such people was extremely low. When we asked how low this number is, they were not able to respond. (According to the U.N. and the World Health Organization the number of people who need methadone therapy in Ukraine is 40,000.)

Pavel has admitted that often methadone patients do give the authorities real reasons to take action against substitution therapy programs, but closing methadone sites isn't the solution. Pavel says that having local powers work together with the police, as well as forcing medical personnel to strictly follow the procedures of providing substitution therapy medications, would lead to better results.

In addition to the press conference, recently many regional methadone sites have been searched by the police. Afterwards, many media outlets published reports exaggerating the drug seizures made during the searches. Pavel commented on this occurrence:

Have you read this Ternopil newspaper? It says: “A criminal group of doctors was detained and 455 mg of methadone were seized.” Please note, not 0.4 g of methadone (which is just 2-3 average doses) but 455 mg – perhaps they think it looks better.

Pavel stated that media coverage of methadone programs is often full of stigma. He wrote:

Odessa Web resource Timer quoted the chief doctor of the Odessa Narcology Clinic as saying: “If only you knew what our nurses have to go through! They might even be killed in the corridor! Each drug addict is a criminal. These so-called patients sometimes threaten our nurses with death threats, demanding an additional dose…”

In Cherkassy, doctors themselves call methadone patients “doomed.” Can you imagine the atmosphere on this methadone site?

A few months ago, Pavel wrote about a decision made by the Donetsk city council to prohibit methadone programs in municipal medical establishments. In his recent post, he analyzes the origins of the city's decision, and what actions the harm reduction community can take to prevent a repeat of this scenario in other cities.

Drop-In Center activists

At the beginning of his entry, Pavel posts a summary of a message he received from a friend in Donetsk. The message reads:

I know a lot about the municipal methadone site that was closed. You just can’t imagine what a mess it was. Almost all the patients took methadone out of the hospital. Some people then sold it and some injected it intravenously. Often people injected in a park right next to the methadone site, which, by the way, is located not far from a police station. The buyers of “smuggled” methadone would wait in cars nearby…

After the municipal site closed, the patients were transferred to medical establishments belonging to the central government. This is where the author of the message received substitution therapy treatment. He goes on to say:

The nurses from our site have caught up to 10 patients who were trying to take methadone out. They told our nurses that they were allowed to do this at the other site.

Pavel responds to this message in his blog, saying:

There is nothing new for me here. It is just one more fact proving that patients should introduce a proper order themselves. I believe that this post just highlights the importance of self organization, self support and self discipline for patients of substitution therapy. I say that the Association of Patients of Substitution Therapy should teach its members how to not to harm themselves.

Pavel thinks that problems in Donetsk occurred because the wrong people were allowed into the substitution therapy program. He argues:

I am positive that if a chronically-addicted person needs medication he will never ever give away his dose. Never! So the issue of selling methadone just would not exist if the right people are selected for the program. If there is a problem of patients selling methadone, it means that the selection commission has shown its professional incompetence. I wouldn't even rule out the idea that all of this was organized by the local powers on purpose to show the “real face” of methadone programs and to give politicians a strong reason to close methadone sites and receive the additional support of voters.

Currently an inter-agency commission, which consists of a chief doctor of a medical establishment, a doctor who is an expert in narcology and a social worker, selects the patients. Pavel questions whether this group of people can adequately select the best patients for the program. He writes:

By the way, this Donetsk nightmare was the result of the inter-agency commission's work. Has anybody ever tested the qualifications of these local “experts” in substitution therapy? Has anybody asked patients to sign an agreement that would set rules they must follow? Has anybody conducted a public awareness campaign for people of the city via mass media to explain the benefits of substitution therapy? I am sure nobody has even thought about this. The grant was received and everything was done according to the law. But besides the legal aspects, there are many other areas you must address if you want to provide substitution therapy.

Has anybody witnessed how “narcologists” conduct these interviews? I personally know a couple of idiots who have become patients of opiate substitution therapy who aren't actually opiate drug users. I have also met people who before coming to the program had tried many types of drugs and had only done a few shots of heroin…

I just do not understand how it is possible, especially when everyone says that it's very hard to get into the program, that the commission often allows totally random people to participate in it. How it possible that the experts cannot distinguish between a chronic drug addict and a person who still stands a good chance to quit drugs?

I just want to conclude that the selection process for substitution therapy programs should be improved. I think that a representative of patients should be included in this inter-agency commission. But unfortunately public health people do not think so…

HIV/AIDS awareness displays in Kiev, Ukraine

Pavel Kutsev, leader of the Ukrainian harm reduction movement and director of the organization Drop-In Center, has been blogging about a new HIV/AIDS awareness program.

His organization, Drop-In Center, recently started the program in Kiev, Ukraine, which is focused on raising awareness among injection drug users about HIV/AIDS. The organization's activists put informational displays in pharmacies that are commonly frequented by drug users.

Here is what Pavel wrote about the initiative:

These displays, made by our own hands, have been placed in a few Kiev “depots” (pharmacies). Not in big fancy pharmacies, but in small and quiet drug stores that injection drug addicts usually visit. You often find corrupted policemen standing next to the entrance of such drug stores, hoping to get some cash from a drug addict coming in to buy a syringe. Volunteers of religious organizations, who often hunt for souls there, see everything but prefer not to intervene. Why do they stay there then? We carefully considered this situation and decided that awareness displays about harm reduction among injection drug users would be a very effective intervention on our part.

Besides nice pictures, the displays contain a “social city map” with telephone numbers and addresses of useful organizations where drug users can receive real help. This information includes prices and addresses of private detox centers and contacts of public HIV-servicing organizations where drug users can confidentially gain various types of assistance, from referrals to medical establishments to being provided with aid such as vitamins, medications, and the exchange of syringes. Most services in such organizations are provided by volunteers who are also HIV positive.

The displays will contain awareness literature on HIV/AIDS issues, including various booklets, leaflets, flyers, brochures, and business cards. Pharmacists will take care of these displays and add new booklets when needed.

It's our secret regarding who has given us official approval to cooperate with the owners of these small drug stores, but we can guarantee that our project won't harm our clients in any way, it will only benefit them by providing useful information.

At the end of his post Pavel writes about other ways that these small drug stores can be beneficial to drug users:

By the way, I believe that this idea of street-based syringe exchange programs (when drug users can trade used syringes for sterile ones for free) are totally out-of-date. There should be permanent sites where drug users can receive syringes and antiseptic napkins, and these small drug stores could serve as such sites. This practice of permanent sites works very well in many European countries and I am sure it will work well in Kiev.

Harm reduction awareness press conference, Kiev (Pavel Kutsev is second from the right).

Pavel Kutsev, leader of the Ukrainian non-profit Drop-In Center, sums up his organization's main achievements in defending the rights of opiate replacement therapy patients. A former drug addict and patient of substitution therapy himself, Pavel uses his leadership position and his blog to advocate for the very specific needs of people like him.

Here is what Pavel had to say about the organization's recent efforts:

Slowly, step by step, we were able to achieve three victories.

1. No more obligatory participation in religious group therapy, which used to be mandatory to stay in a substitution therapy program.
2. No more grinding of pills - only if a patient asks for this.
3. The chief doctor [of the methadone site] promised to provide a room of 5 square meters, which will serve as a day care center for replacement therapy patients.

One might say that these accomplishments are very small, but I would argue against this. The methadone program in Kiev has existed for only one year, but I already know four patients who have died since it has started.

Karman died because of gullet bleeding,  caused by methadone pills which should have been taken as a whole piece but been ground into powder by medical personel.

The other guy died right on the site. He ran away from a hospital the morning after he had surgery to receive methadone pills at the site.

The biggest issue, according to Pavel, is a rule that substitution therapy patients have to come personally to a methadone site to receive medication. Since patients can't get methadone at any other medical establishment, except the methadone site, this poses a challenge for patients who receive medical care that requires staying at a hospital. This is what Pavel posted about the issue:

It really hurts. We understand that this is our fault and we have made this choice ourselves… But why are they so cruel with us now that we have become substitution therapy patients? I wonder why nobody even tries to solve this problem. You just need an agreement with a hospital where replacement therapy patients can get medical examinations and treatments, as well as replacement medications. Patients cannot solve this issue by themselves. They need support from medical personnel, who for some reason seem to be indifferent to our needs.

In mid-August, Pavel submitted a program report to Rising Voices, who have provided Drop-In Center with a micro grant. In the report Pavel highlighted a few more of the organization's accomplishments.

One of these accomplishments relates to the type of drug being used in substitution therapy programs. During the past few months, Pavel has been arguing with Ukrainian health care officials on his Web blog about the medications being purchased by the government. He believes that the medications don't fit the needs of substitution therapy patients since they have a fairly short time of excretion from the body. Patients can only receive these medications once during a 24-hour period, which means they have to go through the pain of withdrawal for few hours a day, since the drugs don't stay in the body long enough. Pavel's voice has been heard by officials, though, as he was invited to represent patients in procuring a new drug for Ukrainian replacement therapy programs.

In addition, in his report Pavel mentions that blogging has helped him gain respect from the public health community. He has been invited to join a few expert groups working on harm reduction issues, and even the police have invited him to talk about the problem.

Every day Drop-In Center receives many phone calls from people living with drug addictions. Pavel and his fellow activists are always available to help with advice and to provide support. They consider the trust the organization has earned among drug users to be their highest achievement yet.

Ukrainian activists of the harm reduction movement

On his Web blog Pavel Kutsev, leader of the nonprofit Drop-In Center, covers topics that impact the lives of people living with drug addictions in Ukraine. He devotes special attention to the recent bans of methadone therapy in municipal hospitals. These bans have been introduced by the city councils of a few Ukrainian municipalities. According to expert opinion, though, the bans were mostly motivated by political reasons, rather than medical ones.

Substitution therapy has been welcomed by the current Ukrainian president,
Victor Yushchenko. So although it's not allowed in municipal hospitals, substitution therapy is still provided in federal medical establishments. Some politicians believe that discrediting the programs that Yushchenko supports will also discredit him.

The substitution therapy bans could be a reason to start a massive public awareness campaign. If we keep silent, we might be shut off everywhere at some point…

What can we do? Write a petition? Collect signatures of supporters? Or is it the right time to start TV debates? If donors would support us financially we could conduct TV talk shows involving professionals, patients and their parents. We could film a video that would touch everyone…

We have to organize a grandiose event. Something like …a march of substitution therapy patients, medical personnel and all the supporters. Actually, to do this we need a week of preparation and a hundred people who are ready to march in support of a human right that is part of the Constitution — to be able to select a medical treatment. At the same time, this march can serve as our protest against those who slow down the development of methadone programs.

Through this public awareness campaign we could tell people the truth about substitution therapy with statistics, facts and data. We should start an open and professional dialogue. We should fight for our rights and not become victims of these local “Sabbaths.”

Although this strategy seems to have many advantages, Pavel also mentions a few risks that should be taken into account.

There is a risk that by organizing a big public awareness event in Kiev we could raise the local issues of Donetsk and Sevastopol [cities that banned the methadone programs] to a national level. This could backfire now, at the onset of the presidential elections, because it might just stimulate a politician's desire to get extra public attention by commenting on the issue. “How can you talk about free drugs for drug addicts in a time of crisis, when the local currency has depreciated, when people are losing their jobs?” they might say.

Pavel concludes:

Yes, there is a serious chance that after starting the public awareness campaign we will hear something like this: “How can we pay for free drugs for these addicts when we cannot provide a decent life for our elderly?” At the same time, I have been listening to these arguments since I started this work.

Up until 1959 opiate drug addicts in the Soviet Union were able to buy morphine for personal use in a drugstore if they had a prescription. Pavel refers to this historical fact and asks his community to take action:

In 1945, right after the end of World War II, the situation in this country was much worse: poverty, devastation, a very high level of criminality, millions of people in Stalin's camps. But all the issues with the availability of morphine were solved.

I do understand that advocacy means addressing all parts of diplomacy, but I do not think that we can postpone being proactive until the elections are over and all the elderly are fed. Every TV channel, for the past few weeks, has been discussing whether or not our police minister was drunk in a German airport. How does this impact the life of the elderly or the rate of HIV/AIDS?

Dear friends, we should move to radical and well thought out action, without regard to any “end of the world omens.” Substitution therapy is one of the most effective tools to stop the epidemic of HIV/AIDS and it is legal — this is the message we should deliver to society. If we succeed, we would significantly improve the lives of those living with HIV and drug addictions. Then smart politicians will even be able to gain votes by supporting our programs and our ideas.

Pavel Kutsev and his wife

A few months ago, Rising Voices wrote about the attempts of some Ukrainian cities to ban substitution therapy programs in municipal medical establishments. Their reasoning was that an addiction to one drug cannot be treated with another drug. However, many experts concluded that this decision was aimed mostly at earning the support of voters, rather than solving medical problems.

After the city Sevastopol put the ban in place, a few other cities in Ukraine introduced the ban in municipal hospitals. Pavel Kutsev commented on this. He says:

With the upcoming elections, the situation with substitution therapy is getting worse and worse. All methadone programs are under threat. It started in Crimea, and now we have cases in Donetsk and Dnepropetrovsk…How would you like this newspaper headline: “Methadone Monsters Ruled by the Hand of Evil?” This is from one of the newspapers from the Sumy region…So we are quite concerned about all this…

In his overview Pavel named another opponent of substitution therapy in Ukraine. These opponents are various religious groups working in the field of drugs and HIV/AIDS prevention. These types of organizations receive a great deal of financial support from local governments. Here is what Pavel had to say about this situation:

By the way, most government funding for the social support of drug addicts goes to various religious organizations. These guys' motto is “Say No to Methadone Hell”…Oh yeah, of course, they are the saviors…Well, if you think about it all, you start to doubt whether substitution therapy programs will survive in Ukraine at all.

Pavel also refers to a problem that seems to be of greatest importance to him: whether the drug used for substitution therapy in Ukraine is the right one. He points out that the drug that the Ukrainian government has purchased for substitution therapy is not the best available drug, as it has a fairly short time of excretion from the body.

According to Ukrainian law, participants of substitution therapy programs can receive these medications only once a day and only in certain medical establishments. A drug with a period of excretion of less than 24 hours essentially means that those taking these drugs experience abstinence syndrome (or withdrawal) for a few hours a day. Pavel says:

To tell the truth, I had started feeling better for a while. My daily dose was 180 mg. In a week my old problems returned… tolerance, shortness of breath, insomnia…

It's been almost a year now since my wife and I started “adjusting” to methadone. To tell the truth, we still need to take antidepressants as the medication just does not suit patients like us well. We are not talking now about the side effects. We just feel that there is no reason for us to increase the daily dose more and more…It does not matter how large your dose is if the active substance will be excreted from the body in 12-16 hours. The only alternative that would work in this case is to consume the medication at least twice a day, in the morning and at night.

According to our estimation, almost all 400 people from our methadone site consume other drugs along with the provided medications. Every third person still shoots up. Others take various pills. This is because in the morning you have such a severe feeling of cold turkey that you just need another drug. You cannot call this a treatment! Please understand! If you are a drug addict and every morning you have abstinence syndrome you just do not feel the effect of the therapy.

The idea of substitution therapy is that while taking medications the person is getting used to sober life and forgets about the nightmare of cold turkey syndrome.

I just need to take replacement therapy medications, like vitamins, to get out of the euphoria habit, which is called “psychological dependency.” I just need to take medications that would support my body and let me function without cold turkey syndrome…for at least 30 hours. Only in this case will the therapy be successful…

What happens if in 15 hours you start feeling pain again and start thinking about a new dose? You cannot even complain to medical personnel as they do not take you seriously. They call the medication they give you “a drug.” Naturally if we consume this medication we are under the influence, we are not adequate…so why to listen to us…

Finally, Pavel sums up his thoughts:

The only option for drug addicts to defend their interests is self organization. Only staying united we can be healthy.

Prescription for a substitution therapy drug

Drop-In Center, the Ukrainian organization uniting people living with drug addictions, has cause for celebration. The Ministry of Health of Ukraine set in motion a system that allows participants of substitution therapy programs to receive their medication in drugstores with a prescription. This move could make life significantly easier and save time for many replacement therapy patients.

The current system forces drug users to go to the therapy site daily to receive medications; they must consume the drug in front of medical staff. In a big city like Kyiv, commuting to the site can take up to two hours each way. Drop-In Center activists have often discussed this issue, repeatedly insisting that for many patients the system poses an obstacle to obtaining a full-time job. The system also doesn't allow patients to leave town, as it is almost impossible to get the therapy in another city. In addition, it limits where a drug user can receive medical assistance. If a drug user is hospitalized he or she still needs to consume substitution therapy medications, but there is only one hospital in Kyiv that is authorized to provide them.

According to the new Ministry of Health regulations, Buprenorphine, a medication used for substitution therapy, is part of the list of drugs that can be obtained with a prescription. Drop-In Center activists believe that methadone, the other widespread substitution therapy medication, should also be included in this list though.

There were a few posts about this news on Web pages administrated by the Drop-In Center. For example, the harm reduction Web site “Motylek” published a statement from the Association of Substitution Therapy Participants:

As of the end of May 2009, there were 3800 participants of substitution therapy programs in Ukraine. Out of them, 850 people use Buprenorphine and 2950 people use methadone…

We welcome the new regulations of the Ministry of Health… We hope that the provision of Buprenorphine via drugstores will make it possible to break the “serfdom” of therapy participants and help reduce the workload for doctors and nurses on the sites…

We are planning to continue our advocacy to encourage the distribution of replacement therapy medications via prescription for all Ukraine sites and are ready to help all people interested in this issue.

The news also initiated a discussion. For instance, Olga Beliayeva wrote:

Guys, I realized how tiring it was to go to the site everyday to receive the medications after I got my first prescription. Now I can receive prescribed medications for weekends and when I need to travel. The bad news is that I had to reduce my daily dose of medication to satisfy the conditions of the new regulations….

It is our life and we need to have the option to receive methadone and Buprenorphine via a pharmacy…We need to have an opportunity to plan our time without regards to the work hours of the replacement therapy site…

Mazay wrote:

So now we can get Buprenorphine in a drugstore. It is great. But what about another medication that belongs to the same opiate group? What about methadone? This situation is strange. For some reason, it is not on the list of the new regulations…. Perhaps we should lobby for its inclusion in the list more actively…