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.

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…

Pavel Kutsev.

Rising Voices grantee Drop-In Center continues to discuss issues that impact people living with a drug addiction. On his Web blog, the organization's leader, Pavel Kutsev, reacted to the Ukrainian government's recent decision to tighten rules concerning medications that can be used by drug users to mitigate the abstinence syndrome (also known as drug withdrawal).

The decision, made by the Ministry of Health and the Ministry of Interior, adds many more medications to the list of drugs that might lead to intoxication.

The Ukrainian drug user community has reacted very negatively to this move, because it means that it will be almost impossible to purchase these medications, which used to be sold freely. A person will now need a special prescription from a doctor before they can buy these drugs.

Pavel posted a few messages he received from the drug user community:

So, no Terpincod for me anymore…What can I get instead? Substitution therapy? Forget it! Perhaps I should start to shoot up again…

Today with Codterpin I could survive somehow. I used it as a sort of substitution therapy. I quit shots four years ago and Codterpin has helped me function and work. I just do not know what I should do now. I have consumed drugs for more than 16 years and I just cannot give up the drugs fully. There are no substitution therapy programs in my town, but it is very easy to buy an illegal drug… This is really terrible. What should I do? I do not want to go to a prison again…

The main argument the government used to justify its decision was that almost all developed European and North American countries sell these drugs only with a doctor's prescription. Pavel responded to this rationalization with the following:

I know that, for example, in France in a drugstore you can buy only condoms and toothpaste without a prescription and, in my ordinary drug addict opinion, this practice is CORRECT. However, I need to make one remark. In France the situation is different. French drug addicts have a CHOICE. Unlike in Ukraine, in France drug users can easily receive substitution therapy if they want to and are able to get the prescribed replacement therapy medications legally in any drugstore. There is a social health care establishment where a drug user can get medical assistance and there is a chance that a doctor would care.

Pavel pointed out the inconsistency in the Ukrainian government's actions concerning the regulation of substances that might lead to intoxication. He contrasted the restricted sale of these medications with the totally unrestricted sale of alcoholic beverages.

Before limiting the availability of medications, which have been sold freely in drugstores over the last 50 years, a government needs to decide what it can give in return. For example, Codterpin was used by opiate drug users for many years as a medication that can ease reactions to going cold turkey. Moreover, this medication has never led to an overdose and perhaps is not more harmful than traditional alcoholic beverages. However, the government, while limiting the sale of these medications, does not even try reducing the sales of alcoholic beverages. Here in Ukraine, you can see advertising for beer and vodka everywhere, any time of the day. By the way, the government could have mandated that alcohol producers direct a part of their profits for social programs, like rehab centers for addicts and substitution therapy programs…as I recall, this idea was actively discussed in the mid-1990s.

Pavel finished his post with a following conclusion:

Before ruining something old, we first need to build something new. Before depriving people of medications they need, we have to give them another option to show that another solution exists. We must think about these people and protect them from returning to street drugs or even committing suicide. Otherwise, lets sell other intoxication-inducing trash like gas and glue with only a doctor's prescription.

Activists of Drop-In Center

Pavel Kutsev, a co-founder of the Ukrainian organization “Drop-In Center,” raises the issue on his Web blog about the specific health needs of people living with a drug addiction.

A patient of methadone substitution therapy himself, Pavel makes the point that the current substitution therapy system makes it difficult for a patient to receive medical care associated a hospital stay. Ukrainian law requires patients to come to methadone sites every day personally to receive the therapy, which makes it a challenge to receive extended medical care at a different site. There is only one hospital in the city of Kiev that is authorized to give patients methadone. Sometimes it's even hard to get qualified medical care at this hospital that would incorporate the specific needs of drug users.

A few days ago Pavel shared the story of one of his friends who died due to the fatal error of medical personnel at this hospital. Below are the excerpts from the story:

When my medical tests were ready I was literally half dead. My body temperature was almost 41C (115.8 F) and my liver probes showed that my liver was almost in coma. This describes my health condition… But we did not even consider the option of going to a hospital…as we are drug addicts, two out of a few thousand patients of the Ukrainian substitution therapy program. We could not afford to miss a dose of methadone, the drug we need like an air. For our bodies, the bodies of the drug addicts, methadone is needed to support the immune system. Without the drug our bodies just stop fighting infections…Only after taking a dose of methadone can other medications prescribed by doctors be effective. And only after taking a dose of methadone can I get a few hours of sleep…

My doctor advised me to get a course of liver treatment in the hospital where I can received methadone. The only hospital where methadone was provided was AIDS Center…I knew that like others, my problem was time. I had to handle all the issues associated with my hospitalization, including all medical tests, in 24 hours. This is the time I could survive without a dose of methadone. Usually I start to not feel well at 4 a.m. and if I do not consume my methadone between 10 a.m. and 11 a.m. I just can not live…

While standing in line at the methadone site to receive my dose, I heard the story of another patient. A girl named Lida, who was also married and had symptoms similar to mine: asthenia, very high temperature, fever, fainting… She did not ask for medical help as she was afraid that she would not get methadone in the hospital and would not be able to survive without it….One day she started to feel so bad that she was taken to the AIDS Center right away from a methadone site. Lida has been on substitution therapy for almost six months and, like all of us, could not live a single day without the medication.

When she arrived at the AIDS Center she was delirious because of her high body temperature…When the doctors learned that she had come from a methadone site, they immediately gave her a medication that is used to deal with an overdose of an opiate drug, and this medication may have killed her…Even a small amount of opiate in the blood of a drug addict helps the body function. Without the drug, an addict starts to suffocate, vomit and have convulsions…The medication Lida was given was for the rapid excretion of opiates out of the body. For a user with a long history of opiate consumption this medication provokes the abstinence syndrome, which leads to liver and coronary insufficiency. After the injection of this medication Lida fell into a coma and died the next day. As autopsy showed that she died because of pneumonia. Her death was aggravated by the absence of opiates in her body as a result of the treatment she received…

Later on we heard that the doctors from AIDS Center contacted the personnel of our site to make sure that Lida did not receive an overdose of methadone. Our doctor said it was impossible… Perhaps, the AIDS Center people first made the anti-overdose injection that killed her and only then asked…

Everybody who deals with narcology knows that for a drug addict the only and most important medication is a drug that contains opiates. That is why none of us who participates in the replacement therapy program will ever miss an intake of the mediation, that is why we are ready to stand in lines under any weather conditions. We just need to avoid going in a delirious state so that we do not get this “anti-overdose injection.”

TB

The Ukrainian Fund for People Living with Drug Addiction's “Drop-In Center” raises the issue of the tuberculosis (TB) epidemic in Ukraine. Recently, its Web site Motylek published several articles describing the scale of this problem, as well as challenges Ukraine faces in fighting the disease.

According to the World Health Organization (WHO) ranking, Ukraine is among the top five countries with the highest TB rates in the world — 78 cases per 100,000 people. According to media reports, today about 100,000 Ukrainians are sick with an active form of TB and 35,000 new cases are registered each year. But some experts say that the real TB situation in Ukraine is actually much worse, since many of the people infected with TB belong to high-risk groups, such as the homeless, drug addicts, and people recently released from prison who don't apply for a medical assistance.

The publications posted on the Web page imply that Ukraine could significantly decrease their TB problem if the country better cooperated with international health aid organizations. Today, the Ukrainian government does not use all available opportunities to receive support from international donors for fighting the TB epidemic. This is happening in part because of weird tax policies and the poor performance of health care authorities.

In the article “TB Epidemic: Ukraine's own fault?” Mr. Andreas Tamberg, a representative of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said the following:

Ukraine has applied for TB funding a few times. In 2008 the government imposed taxes on the TB medications bought with the Global Foundation financial resources, including a 20 percent value added tax and 6 percent customs duty. Consequently, a very significant part of the grant went to the state budget of Ukraine in the form of taxes. This was a reason for us to stop funding of the project. We believe that taxing funds aimed at fighting the epidemic is totally unacceptable. This problem is still not solved.

The other issue with international health assistance is that the health care authorities do not take measures to stop the epidemic, even when they have financial resources provided by the international donor organizations to fight TB .

In 2006, the World Bank temporarily suspended its special loan for combating the HIV and TB epidemics in Ukraine, which had a total value of USD 76 million. According to the World Bank, the reason for the suspension was a lack of progress in project implementation. In other words, the Ministry of Health of Ukraine failed to develop TB and HIV prevention and treatment programs in compliance with the World Bank requirements. From 2003, when the agreement was signed, to the end of 2006 only 2 percent of the loan was used. As for today, according to the World Bank Web site, this project is still on hold.

The head of the public movement “Ukrainians against Tuberculosis” said that in fact Ukraine desperately needs these funds to research and fight the epidemic:

The expert urges that the real situation with the spread of TB in Ukraine could be much worse. It can affect up to 1.5 million people. It is really hard to assess the real scale of the epidemic as Ukraine still does not have an integrated database of TB patients. This database could be developed with the support of the World Bank funds.

Ukraine's government has declared its intention to fight the TB epidemic and to provide all sick people with free medication and medical care, but it just doesn't have enough resources to do this.

According to media reports, the government purchases most TB medications from a local producer. These medications are much cheaper, but more toxic and less effective than modern imported TB drugs. In addition, even these medications are supplied in fewer quantities than what is needed.

The medical personnel of government-funded TB hospitals are substantially underpaid and do not have sufficient social guarantees. This leads to a significant shortage of doctors and nurses in TB hospitals.

Also, the medical facilities used for TB treatment are very old and need to be renovated. Recently, the local Internet community was shocked by pictures of the Kiev TB hospital #2 posted on a popular Ukrainian Web blog Infoporn.

A few weeks ago a Ukrainian Web site, administrated by the Rising Voices grantee Drop-In Center, was discussing the decision of the City Council of Sevastopol. The city has decided to ban the implementation of methadone substitution therapy programs in municipal medical establishments.

Ukraine's Ministry of Health is planning to introduce substitution therapy programs in 111 medical establishments all over the country, based on recommendations by the World Health Organization. However, Sevastopol's City Council members have concluded that substitution therapy just replaces the addiction of one dug with the addiction of another, and so it can't be considered a treatment. Sevastopol's City Council is appealing to all municipalities of Ukraine to follow its example and forbid replacement therapy.

Their appeal may be working. During the last two weeks two more cities in the South of Ukraine have attempted to ban replacement therapy programs. According to a recent post found in Drop-In Center's Web newsletter “Motylek,” the City Council of Yalta voted on whether to ban the therapy in city hospitals, but failed to pass the resolution.

Members of Yalta's City Council who are familiar with public health issues strongly support substitution therapy programs. Svitlana Chirkova, the head of the City Department of Public Health, and Leonid Bankovskiy, the Chief Doctor of Narcotics Laboratory, urged council members before the vote to support methadone programs. As a result, advocates of the ban got only 19 of the 26 votes needed. Yalta City Council members who initiated the vote were very unhappy with these results. One of the most active supporters of the ban, City Council member Mr. Belyayev, said:

We were told by the public health officials that methadone is a drug that does not cause euphoria and doesn't harm the body much, especially the liver and kidneys, and that while taking it an addict can recover. But it is common knowledge that methadone can be prescribed only to incurable drug addicts.

The opponents of methadone programs have promised to continue their attempts to ban these programs. They are also going to start a public awareness campaign to encourage the prevention of drug addiction among youth.

“Motylek” has also published an interview Ms. Valentina Gayvarovska, one of the council members of Odessa Oblast, gave to a local news agency. In the interview, Ms. Gayvarovska stated that the political party that she represents was going to fight to ban substitution therapy programs all over Ukraine. Below are snippets from her interview:

Ms. Valentina Gayvorovska

It would be a shame for Ukraine if under a plausible pretext drug addicts can legally get one of the strongest and most dangerous synthetic drugs.

The United States' experience with substitution therapy has not shown any positive results. More people have died because of methadone overdose than heroin overdose.

According to the government's plan, over the next two years drug addicts of Ukraine will receive free methadone… When the army of methadone addicts will be large enough, the international funds will stop the funding and we will have to buy the drugs for our children, wives, husbands and friends…one gram of methadone costs from $170 to $300.

Methadone therapy decelerates rehabilitation and social adaptation of drug addicts and we should initiate a public discussion and changes of Ukrainian legislation to stop this insanity.

To present another view of methadone treatment programs, organizations advocating for the needs of those with drug addiction have produced a public awareness video, which is being shown on regional TV and posted on the Internet. The video, called “Truth About Substitution Therapy,” has also been posted on the Drop-In Center's three Web sites. It describes the work of a replacement therapy program in another southern Ukrainian city called Simferopol, and shows real people: doctors, parents, and patients who share their opinions about replacement therapy programs. Here is the video:

The doctor from the Simferopol methadone site says in this video that for him substitution therapy is a revolution in narcology, as it is much more effective than any other method for treating drug addiction.

I do not care what politicians say, the only thing I care about are the needs of my patients….As a doctor I see the results and will prescribe this therapy to my patients.

The video also shows a mother who is happy that her son, who, after trying many methods of treatment, has finally returned to a normal life thanks to methadone therapy. A few other patients of replacement therapy programs also talk about how the therapy has changed their lives for good.

Dr. Anar Karazhanova

Ukrainian HIV/AIDS public awareness Web site “ZAPYTAY,” which was developed and is maintained by Rising Voices grantee Drop-In Center, has published an article about a pilot harm reduction project in Kazakhstan. In the past, we have covered the development of replacement therapy in Kazakhstan as it relates to the work of the non-profit organization Mental Health, which recently received a Rising Voices mini-grant.

This particular article states that in January 2009 experimental substitution therapy programs were launched in two Kazakh cities, Pavlograd and Temirtau. The programs currently involve 50 patients and have a budget of more than 7 million tenge ($500,000 U.S.), funded by the Global Fund to Fight HIV/AIDS.

Dr. Anar Karazhanova, director of the Clinical Narcology Department of the Republican Center of Medical and Social Issues, talks about the advantages of replacement therapy:

While receiving methadone, a patient does not get rid of a drug addiction (methadone is also a drug), but he starts to see the world with sober eyes…Consequently, a drug addict whose sense of life used to be about getting a dose, starts to think about his future — how to live, how to earn his living, how to settle his relationships with partners and relatives…

A patient of the program Juliana, age 42, says:

I have tried to quit drugs many times but failed. Every day I have woken up with one goal: to get money for a dose, so to avoid going cold turkey. When I was under the influence of a drug nothing mattered… Methadone allowed me to live without cold turkey syndrome, live a normal life like regular people, where you are able to make plans, solve problems…

To participate in the program, the patients must go through a pre-screening process and satisfy certain criteria. The substitution therapy programs in Kazakhstan are aimed to help drug addicts in mature age, so young drug users are not allowed to participate. Kazakh healthcare officials and doctors prescribe the substitution therapy only for patients who have failed to quit drugs through other rehabilitation programs.

The participants of the program sign a contract promising not to take any other drugs besides methadone. They are supposed to pass medical tests regularly to prove that they are not consuming any “street” drugs. If a participant breaks the contract, they can get expelled from the program immediately. At the same time, participants are not allowed to skip any doses of methadone. Dr. Karazhanova, also the curator of the program, elaborates:

The patients are supposed to receive the treatment once a day at a set time. The dose is prescribed for each person individually. It is defined based on many factors, but the main condition is having the patients feel comfortable. After receiving the dose of methadone syrup the patient has to feel well, not have abstinence syndrome, be able to sleep well, and have a good appetite. When people feel good and sober they can take care of their lives. Five people out of 25 participants have already found a job… Each of the 25 is re-establishing relations with his family. We can talk about certain successes in their re-socialization. This is a goal of our work. Our patients are still drug users, but at the same time they change. One more aspect of substitution therapy is legality. A drug addict does not need to hunt for money to buy a dose of a drug anymore. He does not need to commit a crime, to terrorize his relatives and to hide from police. He receives a stable dose everyday, which according to the doctors helps stabilize his physical condition.

The article also raises the issue of the future of participants in substitution therapy programs. Dr. Karazhanova says that there were quite a few cases when after being in methadone programs for 2 to 3 years, the patients significantly reduced their dose and were later able to quit taking drugs entirely.

However, the Kazakh Internet community has mixed feelings about the implementation of substitution therapy programs in their country. Some of the people are fairly critical and even aggressive. Below is a negative opinion from one of the Kazakh discussion boards:

It is time to help the drug addicts die; there is no sense in treating them. You can treat them now but in 2, 5, or 8 years they will return to drugs anyway. They bring so much pain to their families. When you chop the heads of 10 drug addicts the problem will be solved, nobody else will ever use drugs. When society is too human it leads to drug addiction, alcoholism, violence and thievery…

Other people fully support the opinions presented in the article, though. For example, here is what Zhenia says:

We need to introduce a law about substitution therapy as soon as possible. There is no other choice. This therapy can help many people addicted to drugs and can save many lives.

The introduction of substitution therapy is considered to be an important step in fighting the HIV/AIDS epidemic. The Ukrainian Parliament has adopted a special law that supports the implementation of substitution therapy programs for HIV-positive people. The Ministry of Health of Ukraine plans to introduce these programs in more than a hundred medical establishments all over the country. However, not all local communities are ready to morally accept this harm reduction approach for treating injection drug users.

According to recent reports from Ukrainian news agencies, the City Council of Sevastopol has voted to ban medical facilities that belong to the municipality from providing replacement therapy, which requires the use of methadone or buprinorphine to treat injection drug users. In addition, city council members have appealed to all state and municipal authorities of Ukraine, such as the Ministry of Health Care, the Ukrainian Parliament, the Cabinet of Ministers, and municipal councils to support their initiative and to prohibit the use of public facilities from providing methadone therapy.

In the bill banning the harm reduction programs, the city council stated:

Substituting one drug (heroin) with a cheaper synthetic drug like methadone, which has a stronger addiction effect, does not create any good. It does not help stop the growth of the number of drug addicts in Ukraine. To stop the harmful consequences of public legalization of the synthetic drug…the City Council decided to ban the introduction of substitution therapy programs on the premises, which are a part of municipal property.

The pilot substitution therapy project started in Sevastopol on March 1 of 2009. As of today, it includes 15 patients, and 15 more people are supposed to join the program on April 1. Dr. Georgiy Kadomtsev, the chief doctor of the City Psychiatric Clinic, where the program is being implemented, said that he was going to protest against the decision. He insists that the City Council's decision is based on emotions, rather than on unbiased professional arguments. Dr. Kadomtsev said:

The report of the Council member Mr. Belik [the initiator of the case] totally contradicts the definitions and criteria of diagnostics and treatment of drug addiction…The report has been very unprofessional and just contains random extracts from the Internet.

The head of the Department of Public Health of the City Administration, Mr. Viktor Pologov, called the City Council's ban absurd and said that they went beyond their authority when making this decision. Earlier, he claimed that this campaign against substitution therapy is being supported by forces involved in selling illegal drugs.

Such informational campaigns are organized by those who actually sell the drugs… The annual turnover of drug dealers in Sevastopol makes up about UAH 550 mln (approximately $70 million). Nobody wants to lose such profits. These people stuff the Internet with false information. The City Council decision is 90% based on this false data.

Mr. Pologov stated that in reality the replacement therapy programs could significantly help reduce the rate of HIV/AIDS in the city. He highlighted:

The substitution therapy program is focused on injection drug users living with HIV. Why on them? First of all, we want to reduce the spread of HIV infection in the city. Today every third injection drug user is HIV positive. Providing them with replacement therapy, we protect the ordinary people of the city. Have you seen syringes next to your front doors? Yes, you can see a lot of used syringes on streets and in parks. What if a child starts to play with one of them?…We cannot fight with drug addicts, but we can effectively fight the spread of HIV infection among them. We can reduce the number of infected syringes in the parks and next to our front doors. The City Council members have just decided to leave them there.

The news agencies also pointed out that this medical issue has a political flavor. The morning prior to the City Council's decision, a rally of certain political forces took place next to the City Council building. The protesters accused the current president of Ukraine , who is a supporter of the substitution therapy programs, in promoting drugs.

As a reaction to the political fighting about harm reduction programs, one of the readers of the www.motilek.com.ua noted:

It is very sad that Sevastopol politicians use the problem of substitution therapy just for the promotion of their political forces, and do not care at all about the people addicted to drugs and their problems.

During February and March members of harm reduction programs continued this fight to receive medications that will work effectively. Pavel Kutsev, leader of the Drop-In Center, wrote a post on his Web-blog that has been signed by his counterparts. The post calls for the introduction of a new medication for substitution therapy, since the one being used doesn't help patients return to a normal life.

According to our poll, 47% of patients consume a lot of alcohol. In general only 10-12% of them feel well, 8 out of 10 people use additional stimulants…Only 7-8 people out of 96 say that the dose is adequate for them…for other people this medication just does not work. It does not help them survive even till the morning…We do not really live, do not really work, we are like puppets who are only able to walk to the site, hoping for a few hours of rest from the pain.

The official Web site of the association of substitution therapy patients posted open letters to the tender committee of the major donor for substitution therapy programs in the Ukraine, Alliance HIV/AIDS. The letters were signed by patients from two major Ukrainian cities. The participants of a substitution therapy program from Dnepropetrovsk stated that a few of them had consumed another methadone-based medication, and that the results of this therapy were much better. The patients of a Kyiv substitution therapy center, “Sociotherapia,” highlighted the following facts in their open letter to the tender committee:

According to the Ukraine's legislation, medications for substitution therapy cannot be prescribed, so it is not possible for us to consume the medication several times a day. Our request is to purchase a medication that would have a longer time of excretion from the body and less side effects, such as high tolerance, high diuretic effect, and oppression of sexual function.

The letter provides the following conclusion:

To achieve the goal of re-socialization, drug addicts should have a life…without the abstinence syndrome. So there is a need for medication that would last at least 24 hours without heavy side effects … Otherwise the effect of the therapy will be reduced to a few hours of relief from the pain and there won't even be a hope for sick people to have an active and adequate life.

Pavel is currently one of the activists in a harm reduction program in the Ukraine, and was a drug user for about 30 years. He is a co-founder and leader of the Ukrainian foundation for injection drug users called Drop-In Center.

Here is his story:

I got a phone call early in the morning…”Who could it be so early?” I wondered, looking at my watch. It is 7:15… Then I hear the cheerful voice of an elderly woman: “Good morning, Pavel! I know I woke you up, but you said I could call any time, especially if we are talking about the orphanage.” “Oh yes…I remember,” I lied, but immediately recalled that this woman had already called a few times …

“My name is Natalia Ivanovna.” It seemed she has read my thoughts and I bet she was smiling.

“Oh yes, sorry for this Natalia Ivanovna.” I lit a cigarette and recalled that some time ago I had promised a woman who had introduced herself as a director of an orphanage to visit her school and to talk to the children.

“They are in their 8th to 10th year of study; they need something non-typical, not boring, something that would touch them,” she said.

At first I said no, I remember. I told her that our community is very specific, we are not young and have lived with the drug addiction for many years and prevention is not our field.

“Well, there are so many organization in Kiev,” Natalia Ivanovna sighed. “But when I ask them to come and talk to our kids about this problem, nobody has time, everybody is busy with something more important…By the way, this is the third time I am calling you.”

“Really?” I felt cold in my stomach and decided that I MUST go there. “I am really sorry, I promise I’ll come”…

Then I realized that I was in trouble. Oh my God! What can I tell these youngsters who by age could be my grandchildren!?

“Just do not panic,” my wife tried to calm me down. “Take a laptop with you, ask them to make some tea, sit with them around a table and start talking about life. After all, why do people put themselves through various troubles?”

“Because they are stupid” I said.

“See! Then show them pictures from our booklets and newspapers. Then, turn on quiet music and show the pictures we made on the other side of life…Really, just make a slide show. Just let them see. Show them the girls serving strangers in the bushes next to a highway just to get a shot. Let them see decaying sores or how they take shots in the groin or neck…Show them pictures of Kirill, Zheka, Lekha, Ira, Tim and the pictures from their funerals…When you are done ask these kids whether they want to become drug addicts.”

I do not want to describe the eyes of the kids when they watched the pictures, where their peers in a year or two looked 20 years old, where they got crazy, remote…

I wanted to hear from at least a few of those kids who had listened to me. I asked, “What feeling do you have toward the people you have just seen on the screen? Do you feel contempt or indifference or sympathy?”

Twelve out of twenty told me what I very much wanted to hear. They felt sympathy.

We parted like good friends. The director, Natalia Ivanovna, told us that she had never heard such a sincere conversation with her kids. Some pictures even affected her, she who had served as a military medical surgeon for 11 years right on a battlefield in Afghanistan.

I do not know why, but that night I did not feel tired, even though I came home very late…..

P.S. The address of Boarding School #7 is Ukraine, Kiev, vul .Beletskayam 55