In a video appeal filmed in April by patients from opioid substitution therapy (OST) programs in Crimea, which had just been annexed by Russia, a personable man named Andrei warns: "Without this program, I may die."
Unlike in Ukraine and many Western countries, opioid substitution therapy (OST) is illegal in Russia. His words came true. Andrei hung himself in December, unable to cope after Russian authorities cut off access to OST in May.
"It seems like all the time I hear about someone else who has died," Igor, a Crimean OST patient and activist who organized the video appeal, told VICE News. He had just learned that another former OST patient, also named Andrei, died last week of an overdose in Simferopol. Eight patients he knows have died, Igor said.
Of the 800 drug users who had previously received OST in Crimea, at least 80 have died since the programs were shut down, mainly from suicide and overdose, according to United Nations AIDS envoy Michel Kazatchkine.
As well as Russia shutting down the program in Crimea, the conflict has also meant that the Ukrainian government has stopped distributing OST drugs in the rebel-held east of the country.
Detailing a report that will be given to UN Secretary Ban Ki-moon, Kazatchine warned of a "humanitarian crisis" in eastern Ukraine, where 300 patients have lost access to treatment since Ukraine's government ceased distribution there. Another 550 patients could be cut off from treatment by the end of February.
Besides the death of patients, the end of OST in Crimea will likely also add to eastern Europe's growing HIV epidemic, which is largely driven by intravenous drug use, according to the UN. (Sexual transmission of the virus is now more common in Ukraine, following several years of OST programs.) Increased numbers of new HIV cases have been reported in Ukraine, Russia, Bulgaria, Armenia, Belarus, Turkey, Georgia, Azerbaijan, Moldova, and Romania.
Even the Russian authorities, which have vigorously opposed substitution therapy and provided little support for harm reduction programs like needle exchanges, have admitted the situation in the country is "tense," with nearly a million people living with HIV in Russia in November 2014. The official number, 864,394, is likely to be several times too small according to the WHO's "iceberg principle" that only a fraction of cases are reported.
As part of OST, a treatment that is backed by the UN, patients receive methadone tablets, a safer substitute for heroin, and buprenorphine to ease dependence. Under medical supervision, drug addicts are able to reduce intravenous drug use, which otherwise drives many to prostitution or crime to fuel their addiction, while also contributing to the spread of HIV and Hepatitis C through shared needles.
In addition, OST helps patients, many of whom are HIV-positive, stick with other treatment programs like antiretroviral therapy, which suppresses HIV in the bloodstream and prevents the spread of the virus.
Many long-term OST patients are able to hold down jobs and raise a family, according to Pavel Skala, associate director of the International HIV/AIDS Alliance in Ukraine. If they lose access to substitution therapy, only 5 to 10 percent are successful in other rehabilitation programs, he estimated. The rest go back to street drugs and crime, or commit suicide.
"The exit from the program means the start of bad results," Skala told VICE News. "Ninety percent of them can't stop using, they switch over to drugs, mostly bad, dangerous drugs… It's the same as throwing them out on the garbage heap."
Lyudvika, an OST patient from Yalta, said when it became clear last spring that the new Russian authorities would shut down the program, she and other patients began trying to reduce their doses by breaking up the methadone tablets they received, so it wouldn't be quite as jarring when the supply was cut off.
When the end came on May 15, Lyudvika switched to using painkillers and said she was able to finally kick her addiction in September. But most patients weren't able to cope.
"People were socialized, they had jobs," Lyudvika told VICE News. "Now they're on the streets, in the best case. In the worst case, they died. I know lots of them."
"People were participating in the program for many years," Igor said. "These people got used to getting vital medicine legally, and then in one day, they became illegal, and to deal with their pain they had to begin breaking the law. The drug addict doesn't do it to get pleasure but just to survive."
Sixty OST patients moved to Ukraine to continue treatment there, while a few dozen went to Russia, Skala said. (One of the patients from the video appeal, Anton, died of an overdose in St. Petersburg.) But most remained at home in Crimea, often for family reasons. Long-term drug user and patient Irina Borovko, for instance, stayed to take care of her three sons, one of whom lost both of his arms in a childhood accident and needs assistance every day.
An influx of former OST patients onto the streets, in combination with the economic embargo adopted against Crimea by the US and the European Union, has contributed to the spread of increasingly low-quality drugs, Igor said. For instance, krokodil, a codeine-based drug that literally rots users' skin to create scaly contusions, has long been popular in Russia but only recently appeared in Crimea.
"There are no European drugs in Crimea, there's no heroin or cocaine," Igor said. "People here use home-made heroin called 'cheky,' but after what happened there's a big deficit. People have been forced into 'pharmacy' drug habits, the stuff that's in Russia, like krokodil.
"Nine months have passed, but to this day former patients hope that the new regime will revive substitution therapy in one form or another," Igor added. "What's left besides hope?"
Follow Alec Luhn on Twitter: @ASLuhn
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