Death by disdain: the fate of drug users in Russian-occupied territories

With replacement therapy now illegal, drug users in Russian-occupied Crimea and the self-proclaimed republics of the Donbas are finding it hard to survive.

In 2014, Donetsk native Yevgeny Selin had his own business, a car and an apartment he bought with his own money. Besides work, Selin was involved in civil society, fighting for the rights of drug users, and was in contact with representatives of Ukraine’s Ministry of Health.

As Yevgeny recalls, his life had been very different just a few years prior. “There were good times and bad times, but mostly it was bad times. I was totally addicted to heroin — I started using when I was around 13 or 14. When we were boys we used to look for or steal poppies in other people’s gardens, this was in the Oryol region, where I used to live, poppies grow everywhere. It was harder in the winter, you had to steal more. Then I moved to Ukraine and started taking crystal meth. When you’re using, you’re always either looking for money or drugs. Or you’re doing the drugs — you do them and go to sleep. And that’s your life.”

In 2008, Yevgeny’s life began to change. A programme from drug replacement therapy was launched in Ukraine, sponsored by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Ukraine’s parliament had stated that therapy standards “are in line with Ukrainian legislation” back in 2004, which was when the first pilot programs for the therapy were launched in Kherson and Kyiv.

Methadone replacement therapy, to be more precise, is practiced in all EU countries, as well as in the USA, India, Cambodia and China. There are 1.3m patients enrolled in treatment today. However, the therapy is banned in Russia. Russia’s top narcologist, Yevgeny Bryun, told oDR that “methadone therapy is just a business,” and that Russia will never have such programmes.

For drug users from Crimea and eastern Ukraine, Russian jurisdiction spelt disaster.

Goodbye to withdrawal symptoms

HIV rates in Ukraine remain high: 0.5% of the population lives with HIV, and 60% of those people are drug users who use needles. It is believed that replacement therapy will curb the HIV infection rate, because instead of injecting street drugs, drug users will take medicine such as Metadol (active ingredient: methadone) or Ednok (active ingredient: buprenorphine).

Drug replacement therapy does not result in withdrawal symptoms or euphoria. Typically, the patient comes to a distribution site, gets a glass with the medicine in liquid form, drinks it, and leaves. The drug users no longer have to look for drugs, they stop having problems with the law, and they start having free time — time they used to spend on searching for drugs or money.

Drug replacement therapy does not result in withdrawal symptoms or euphoria.

People who have regularly taken opioid drugs (such as heroin) for over three years can participate in the program. Pregnancy or a serious chronic disease — for example, if the patient is living with HIV — are other factors that determine one’s inclusion in the programme. When a drug user decides to start replacement therapy they submit an application, sign an agreement to not sell the medicine, go through medical tests, and visit a narcologist (i.e. an addiction specialist).

The final decision for inclusion in the program is made by a multidisciplinary committee: two doctors, a social worker and a local project leader. When therapy begins, the doses are gradually increased so that the medicine completely replaces street drugs.

The first effects from therapy become evident within three months: most patients report that their physical and mental health is better and that they’re starting to be part of society again.

After a while, if the patient is completely clean and ready to stop the therapy, the dose of the medicine is gradually decreased until the patient is no longer on it. This usually happens over several years. Today, there are 176 active therapy centres in Ukraine, with a total of 9,806 patients.

Yevgeny sent an application to participate in the program right away, back in 2008. “Slowly, life began to change. I stopped shooting up immediately,” he recalls. “My old relationships began to repair themselves, friends saw that I was a different person, I won back their trust. I launched my own construction business; we worked on small projects, including street stalls and small shopping centres. We sold them to local businessmen — it was very profitable, and my salary was good by Donetsk standards. I bought a car and an apartment.”

“Did you want to spend your whole life high?”

As soon as Crimea was annexed by Russia in 2014, the government immediately moved against drug replacement therapy — doses were sharply reduced and then therapy was halted altogether. Leftover medicine was burnt.

Anastasia (a pseudonym), who asked me not to reveal her city of residence in Crimea, left prison in 2007, when she was 29. In 2012, she started taking methadone and was able to find work as an English teacher. She took care of herself, her young daughter, and her mother.

For people like Anastasia, the therapy ban was catastrophic. Like other patients who spoke to oDR, she did not want to go back to street drugs, to lose her job and her family, but she was afraid of withdrawal syndrome. All this came after the Russian government insisted that no patient would be left behind and all would be given aid.

For the five years that we took methadone, we got our lives back. We stopped being street addicts.

Natalia, a native of Sevastopol, was addicted to opioids for 25 years. Her medical file was marked with the number 1 — she was the first patient to get replacement therapy in Crimea.

“For the five years that we took methadone, we got our lives back. We stopped being street addicts. The cancellation of the therapy programme in 2014 was cruel, painful, and terrifying. I signed myself into a psychiatric facility, spent ten days there, and was simply horrified by the medicine they gave us — it put you in a fog but did nothing against withdrawal symptoms, nothing for the pain and fear. I seriously hurt the right side of my body while going through withdrawal symptoms in a bed with sharp netting, and when I asked the nurse for help, she snapped, ‘Did you want to spend your whole life high? Now you’re paying for it’.”

“They sat outside doctors’ offices, crying and knocking on doors”

Natalia refused to be hospitalised, left the facility and started taking street drugs. Eventually, local doctors suggested she go for treatment in Moscow — in 2014, former therapy patients were given Russian passports very quickly, so many could depart for the mainland. Natalia says she’s one of the few who was given real help. Today, she’s clean.

Alexander, a patient who lives in Sevastopol, told a representative of the Andrei Rylkov Fund for Health and Social Justice about how the programme was cancelled in Crimea. Doses were drastically reduced, while clinics didn’t even have the most basic medical supplies. For those who could afford to pay about 5,000 hryvnia (which amounted to around 15,000 rubles or £430 in June of 2014), everything could immediately be found, even Ednok (buprenorphine), which was technically already illegal.

When therapy was cancelled, former patients were given minimal amounts of painkillers and sleeping pills.

“Other people, who paid [only] 1,500 hryvnia didn’t get that kind of [help],” Alexander said. “They sat outside doctors’ offices, crying and knocking on doors.”

When therapy was cancelled, former patients were given minimal amounts of painkillers and sleeping pills. Trying to find help, they went to Simferopol, but there were no beds available for them.

Besides lack of adequate medical help, Crimean drug users were faced with pressure from the authorities. According to Anastasia, friends of hers had their privacy invaded: “People came to distribution centres and stood in line by the office, where they gave out medicine. And they were told, ‘If you don’t give us your personal information, you don’t get access’.”

Anastasia’s words are confirmed by the conclusions drawn by France’s Pompidou group. Their report, published in 2014, says that after the annexation of Crimea, drug users began getting visits from the police — there were registered cases of the confidentiality of their medical records being violated. There is at least one known case of a man who was fired when his boss found out that his employee was a drug replacement therapy patient.

A hundred dead — or more?

Anastasia did not want to go back to street drugs and had no hope of getting aid in Crimea, which is why she immediately left for Dnipro (formerly known as Dnipropetrovsk) — to continue therapy. According to the OSCE, around 100 people made similar choices.

Among Crimean residents there are also those who, like Natalia, went for treatment in Russia. According to data provided by Tatyana Klimenko, assistant to the Russian Minister of Health, 113 out of 806 Crimean patients in replacement therapy made the trip.

Yet not all got the help they needed in Russia. A former therapy patient (who asked to remain anonymous) told oDR that he personally knew Anton, a Crimean native who agreed to be treated in St Petersburg. The alternative treatment method did not work. Anton died of an overdose.

According Michel Kazatchkine, the United Nations Secretary-General’s Special Envoy for HIV/AIDS in eastern Europe and central Asia, the cancellation of the drug replacement therapy programme has led to the deaths of at least 100 people in Crimea.

Pavel Skala, the policy and partnership director at the Alliance for Public Health Fund (“Alliance”), believes that the real number of deaths in Crimea is higher: “According to our estimate, by 2014, up to 120 had died. We stopped tracking the deaths as to not endanger people in Crimea, because the Russian government was actively opposing information-gathering efforts. But we know that former therapy patients in Crimea are still dying. Three years later, the number of the dead is much greater than 120.”

According to our estimate, by 2014, up to 120 had died.

Russia’s chief narcologist, Yevgeny Bryun, disputes these numbers and believes they are inflated. Yet four former therapy patients from different parts of Crimea have confirmed to oDR that most of their friends are dead, and those who are not dead are using street drugs again.

Want therapy? How about a war instead?

In 2014, Skala’s organisation launched a special programme for displaced people from Crimea. This allowed Anastasia, who came to Dnipro, to receive 260 hryvnia per day (this included a housing allowance). A few months later, the programme had to expand, so that patients leaving the Luhansk and Donetsk regions could get help. Since the conflict broke out in eastern Ukraine, drug replacement therapy has stopped there too.

Yevgeny Selin also became a client of the Alliance’s programme after he fled Donetsk for Kyiv, not wanting to go back on street drugs. When Yevgeny made it to the Ukrainian capital, he discovered that the so-called Donetsk People’s Republic (DNR) had put out a search warrant for him, labelling him a pro-Ukrainian activist.

Yevgeny was able to leave quickly, but Andrei, another therapy patient in Donetsk, was in town when the war started. Andrei told Alliance that people with automatic weapons came to their distribution centre and forced patients to dig trenches.

People with automatic weapons came and forced patients to dig trenches.

In spite of help being offered, most did not dare leave. Drug users have a hard enough time looking for work and building relationships in their own cities, let alone starting over anew. Before the war, there were 759 patients registered in the Donetsk region, of which 327 have now left. In the Luhansk region, 639 were registered, and 289 have left. According to data from 1 February, 2016, Alliance had 207 clients who made the move from the two regions.

According to the available witness reports, most of the patients who remained in territories no longer controlled by Ukraine are dead, or else using street drugs. Precise data are not available.

Yevgeny lives in Kyiv and has no plans to return to Donetsk. In Kyiv, he has a girlfriend, and on the day of our interview, they went shopping together and then took a stroll through the city streets. In Donetsk, without drug replacement therapy, his life would be very, very different.

Translated by Natalia Antonova. This story was originally published by openDemocracy. It is published under a Creative Commons Attribution-NonCommercial 4.0 International licence. If you have any queries about republishing please contact openDemocracy. Please check individual images for licensing details.