The annexation of Crimea by Russia is already having a potentially deadly affect on one local population group – a group of patients on substitution therapy.
Supplies of the drugs they need for everyday functioning have been halted from mainland Ukraine since the end of February. With stocks on the peninsula set to run out within 10 days or less, 800 patients and their families are facing the end of what, for them, is a life-saving treatment.
“There’s just no limit to our worry right now,” said Almira Mischenko, whose son Philip is receiving substitution therapy. “Without this program we would have buried our children by now. If it stops, we’ll be back in hell.”
Opioid Substitution Therapy is a medically-based response to long-term drug addiction. People who have tried and failed to stop drug use can receive a substitution drug that is less addicting -- often methadone or orbuprenorphine -- under medical control. This enables them to quit their dependence on illegal drugs, bringing them back into mainstream society and enabling them to receive regular medical treatment for related health problems like hepatitis C and HIV.
The form of therapy is used in countries from Canada to China as part of broader strategies to tackle the spread of HIV and other health and social harms associated with illegal drug use. It has been a key part of Ukraine’s HIV prevention strategy since 2006, with around 8,500 clients now enrolled around the country.
Ukraine experienced an explosion in injection of home-made opium, or "shirka," in the late 1980s, which rapidly led to one of the rates of HIV spread through injecting drug use worldwide. Since the introduction of harm reduction programs in Ukraine, rates of new HIV cases among people who inject drugs have fallen from 7,127 in 2006 to 5,847 last year.
Clients of the substitution therapy in Simferopol say the therapy has lifted them out of the despair that drove them to drugs in the early 1990s.
“We saw the mess all around us and we just wanted to die,” said Tatiana Pashkovskaya. “Drugs were a way to escape the awful reality … In the end I came here because I realized I’d throw myself off a cliff otherwise.” Pashkovskaya has been on Opioid Substitution Therapy since the program started. Now she and other clients have homes, families, regular jobs, hobbies. “In these eight years I’ve realised we can live differently; think of other things than drugs. This program returned us to life.”
Substitution drugs buprenorphine and methadone are supplied to the therapy sites throughout Ukraine from Kharkiv, with a required armed escort.
State security services decided it was too dangerous to attempt to get through road blocks set up on roads into Crimea from Feb. 27, manned by armed Russian soldiers and local self-defense and Cossack groups. Local pharmacies are not allowed to stockpile drugs for longer than one month, so stocks soon began to run low. Hold ups at road blocks are also affecting supply of medications for HIV and TB, so a potentially much larger group of Crimeans may soon be affected.
The International HIV/AIDS Alliance in Ukraine, which manages Opioid Substitution Therapy programs in Ukraine, has been working together with local coordinators to restart supplies. But the Crimean program faces a bigger problem than roadblocks. Substitution therapy is banned in the Russian Federation. Now that Crimea has been formally annexed by Russia, Russian laws apply here.
On March 20, Viktor Ivanov, head of the Russian Federal Drug Control Agency, announced that the agency would begin work in Crimea immediately, and that its first action would be to halt the use of methadone to treat drug addiction.
In Russia, injecting drug users represent nearly 80 percent of all HIV cases in the Russian Federation.
Simferopol clients are well aware that this form of therapy is banned in Russia. One person came all the way from Kazan, Russia, to Simferopol to enroll here. Yet they all voted in the recent referendum to join Russia. It never occurred to them that this might affect their own program.
“We’re for Russia with both hands,” sad Ruslan Guzik, one of the program’s first clients. “We really hope Russia will help us now, we can’t believe Russia will just dump us back where we were before this program started.”
Doctors, HIV specialists and advocates fought a long battle to get the substitution therapy accepted in Ukraine. Now the community is preparing for a similar battle with the new Crimean authorities and with Russia.
“Politics is politics, but life is life. So we want to appeal to the administration, to [Crimean Prime Minister Serhiy] Aksyonov,” said Mischenko, whose son attempted suicide twice before he started getting treatment. “We’ll go right to Putin if we have to, because this is just unbearable.”
Anton Basenko, from the Ukrainian Association of Opioid Substitution Therapy Clients, is not hopeful.
“A few days ago we thought we could solve this,” he said. “We thought it was just the technical problem of how to get the drugs to Crimea. But it will be almost impossible to agree anything on the ground now that the issue has reached such a high level in Russia. Even if the drugs reach Crimea, because they are banned in the Russian Federation anyone involved in OST – doctors and patients – can be prosecuted under criminal law.”
Vladimir Stroyevsky, head doctor of the Crimean Narcological Clinic, told the Kyiv Post that people were trying to make a ‘political game’ out of the current situation. “No one is trying to destroy what was built up here over eight years,” he said. “The clients are people with their suffering and no one intends to make them suffer more.”
Stroyevsky said OST patients were already on reduced doses, and would soon be moved to alternative therapies like rehabilitation or cognitive behavioral therapy. “We’re working with our patients, informing them of the situation. Some say they’ll move to Ukraine to get substitution therapy. We’re ready to implement alternative programs here.”
Many Simferopol clients have tried other treatments, but found that only OST could help them. If their supply of methadone or buprenorphine stops, they fear they will be forced back onto the streets to look for illegal drugs as the only way to cope with severe withdrawal symptoms. Most of the clients also have serious health problems including HIV, and their health is bound to suffer.
“We’ve been on this therapy for eight years; it’s in our system,” said Guzik. “We can’t live without it now.”
But so far, Simferopol clients reject the idea of moving to mainland Ukraine to continue the therapy.
“How will we live there – with what means?” said Marina Ustinova, whose husband is being treated. “I want my family to live a normal life in a normal country and that is Russia.”
“I think Russians just don’t understand substitution therapy,” added Yelena Plakhonina, Marina’s mother-in-law. “They haven’t had a chance to understand what it is and how it works. I know if they could see how it has changed our lives, they would support it.”
Editor’s Note: This article has been produced for Kyivpost with support from the project www.mymedia.org.ua, financially supported by the Ministry of Foreign Affairs of Denmark, and implemented by a joint venture between NIRAS and BBC Media Action.The content in this article may not necessarily reflect the views of the Danish government, NIRAS and BBC Action Media.