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I. Summary

I’m not going back there. There’s no point, they don’t cure you. I would go to the detoxification clinic if they actually helped [me] there. I’m sick and tired of injecting. But I can’t do it [withdraw] at home… I would like to live to 30 at least...¹

                —Svetlana S., 25 years old

Illicit drug use is a serious problem in Russia today, with estimates of the numbers of users ranging between 3 and 6 million people.² Many of these people—though by no means all—have developed drug dependence, a serious chronic, and often relapsing, disease as a result of prolonged drug use.³ As is the case with people affected by other diseases, persons dependent on drugs have a right to medical care for their condition, both under Russian and international law. Indeed, Russia has an extensive system of state substance abuse clinics that offer services for alcohol and drug dependence and has, in the past few years, invested considerable funds into the development of rehabilitation centers for people dependent on drugs.

Yet, despite the recognition by the Russian government of the importance of drug dependence treatment, research by Human Rights Watch in Russia, including detailed field studies in Kazan (Republic of Tatarstan), Kaliningrad, and Penza, shows that the vast majority of individuals addicted to drugs in Russia do not have access to evidence-based medical care to treat their dependence. Russia has made policy decisions relating to the provision of medical treatment for drug dependents that are inconsistent with and in violation of its obligation to provide, within available resources, health care that meets the criteria of available, accessible, and appropriate. While detoxification treatment is widely available throughout Russia, rehabilitation treatment remains unavailable in many parts of the country. Private drug dependence clinics, some of which offer evidence-based rehabilitation treatment, are often unaffordable for drug users. Various obstacles keep drug users away from seeking treatment at state clinics, including the risk of restrictions on civil rights by being registered as a drug user, breaches of confidentiality associated with treatment, and a widespread distrust of drug treatment services that also undermines take-up rates. The treatment offered at detoxification clinics does not follow lessons learned from decades of research on effective drug dependence treatment modalities. On the contrary, policy decisions relating to what drug treatment programs can be offered deliberately ignore the best available medical evidence and recommendations, and as such arbitrarily restrict drug users’ access to appropriate health care.

Despite these important failings of the drug dependence treatment system in Russia, healthcare institutions, policy makers, and the Russian public routinely blame drug users for the failure to overcome their drug dependence. In its research, Human Rights Watch was repeatedly told that drug users simply lack the motivation, character, or perseverance to stop using drugs. Various officials are currently advocating new laws and policies that would enable the state to force drug users to undergo treatment. Undoubtedly, some drug users do not want to end their drug habit. But various studies show that almost all drug users in Russia who have used drugs for more than one year have made multiple attempts to stop using, either at healthcare facilities or on their own. Every single one of the around 60 drug users Human Rights Watch interviewed for this report had made at least one attempt to stop, and many had made multiple attempts.

Studies repeatedly demonstrate, however, that, no matter how strong a drug-dependent person’s motivation to address his or her drug use, the odds are that he or she will not succeed without access to an evidence-based drug dependence treatment program. Drug dependence is a chronic disease that often relapses, even for drug users who participate in proven treatment programs and are committed to their treatment. For many people affected by the disease, there are biological and psychological reasons why will power does not suffice to overcome the disease—just as people who suffer from depression cannot overcome their condition on will power alone but need medications, therapy, or a combination of the two.

A considerable part of the blame for the drug dependence treatment gap thus lies with the Russian government and Russia’s healthcare system, which leave most drug users who wish to stop using drugs or to gain control over their addiction to their own devices in the face of a serious chronic disease. As a result, many drug users who might otherwise have successfully entered into treatment programs are condemned to a life of continued drug use with its increased risk of HIV infection, other drug-related health conditions, and death by overdose. But Russian society also pays a price for the state’s failure to provide easily accessible and evidence-based drug dependence treatment services. In other countries, evidence-based treatment of drug users has been shown to lead to considerable savings on drug-use-related law enforcement efforts, incarcerations of drug users, and healthcare costs due to HIV, hepatitis C and other drug-related health conditions.

The right to health, which Russia has explicitly recognized in its constitution and by becoming party to various international human rights conventions, requires states to make healthcare services available for people affected by disease, including by drug dependence. These services must be accessible—without discrimination—for people who need them, and have to be culturally and ethically acceptable, scientifically and medically appropriate, and of good quality. Although the right to health, in recognition of the great variation in resource availability in different countries, is not prescriptive about a specific standard of care that has to be provided, states are obliged to work toward full realization of the right and to progressively improve the care offered. A rights-based health policy also requires states to ensure that policy decisions and choices are objective and evidence-based, directed towards maximizing the right to health of individuals, and not made on criteria that are discriminatory, arbitrary, or have an unjustifiably restrictive or negative impact on the enjoyment of the right to health, in comparison to other available policy options.

Availability of drug dependence treatment is mixed in Russia. While there are narcological clinics in all major towns of Russia, most of these clinics offer only detoxification, which, on its own, does little to help a drug user achieve a lasting remission.⁴ State-run rehabilitation or relapse prevention centers, which provide the crucial second phase of drug dependence treatment by helping drug users manage psychological craving for drugs, exist in only 26 of Russia’s 85 regions. In some regions commercial or faith-based rehabilitation centers exist, but treatment at the former is often too expensive for drug users while many drug users do not feel comfortable using the latter.

One of the most effective and best researched drug dependence treatment modalities for opiate dependence known today, methadone or buprenorphine maintenance treatment, is altogether unavailable in Russia. Although dozens of countries have successfully used these medications in the treatment of drug- dependent persons for several decades and the World Health Organization and the United Nations Office on Drugs and Crime have strongly endorsed them, their use is explicitly prohibited by law in Russia. Top officials in Russia, including in the healthcare sector, oppose their use on the mostly ideological ground that it substitutes one drug for another. The policy decision not to make methadone and buprenorphine available for the treatment of drug-dependent persons, based on factors that ignore medical evidence, can only be described as arbitrary and unreasonable, and as such is a failure of Russia’s obligation to fulfill the right to health.

Accessibility of treatment, the second requirement under the right to health, is highly problematic in Russia. Whereas research indicates that drug treatment services should be easily accessible so as to ensure that as many drug users make use of them as possible,⁵ in Russia numerous barriers exist that keep drug users away from these services. Most drug users distrust state narcological clinics; they do not believe that the treatment offered is effective, and see the clinic staff as corrupt and uninterested in their recovery. State narcological clinics in the regions we visited have done little to counter this distrust. A central, and easily remedied, obstacle to treatment seeking is the fact that clinics in all three regions tell drug-dependent persons who voluntarily seek help—behavior that states should clearly encourage—that unless they pay for their own treatment, their names will be entered into a database of people considered to be drug dependent—under Russian law, all drug users who seek free treatment at state narcological clinics are placed on this state drug user registry—and that consequently certain restrictions will be imposed on their rights. Other factors that keep drug users away from state narcological clinics are the cost of paid treatment, including out-of-pocket charges for medications patients are supposed to receive for free, the requirement to collect paperwork on various health conditions prior to admission, and poor conditions in the clinics. Most drug users therefore do not believe that the treatment offered is effective, and they see the clinic staff as corrupt and uninterested in their recovery. State narcological clinics in the regions we visited have done little to counter this distrust.

Russia also fails to meet the requirement that treatment services offered be “scientifically and medically appropriate, and of good quality.” Decades of research into drug dependence treatment have created a vast body of evidence on the effectiveness of various treatment approaches. These findings have been summarized, among others, in the United Nations Office on Drugs and Crime’s “Drug Dependence Treatment Toolkit.” Yet, Russia has made little effort to incorporate lessons learned into its drug dependence treatment services.

Research findings, for example, underscore the fundamental importance of beginning psychosocial interventions with patients during the detoxification stage to motivate them to stay in treatment after detoxification is over.⁶ However, we found that this hardly happens in Russia’s drug dependence clinics. First of all, patients are generally heavily medicated with tranquillizers and antipsychotic medications, even if research shows that this is not necessary for most patients.⁷ As a result, patients are often in a reduced state of consciousness, making counseling efforts difficult or even pointless. Secondly, we found that only very limited counseling took place. Most drug users said that a psychologist or peer counselor from a rehabilitation center had talked to them about the possibility of continuing treatment but that that was the extent of psychosocial interventions. Various drug users mentioned extreme boredom while in the detoxification clinic. Patients are also generally not counseled on HIV while in the detoxification clinics, although best practice standards for drug dependence treatment recommend that such counseling take place.⁸ Research also demonstrates the high effectiveness of methadone and buprenorphine maintenance programs, which, as mentioned above, are prohibited in Russia.

There is ample evidence that the state drug dependence treatment system in Russia is largely ineffective. In a 2006 survey of almost 1,000 injection drug users in 10 Russian regions conducted by the Penza Anti-AIDS Foundation, 59 percent of drug users who had made use of the state treatment system had gone back to using drugs within a month of finishing their treatment course; more than 90 percent had relapsed within a year. Various other studies also found that less than 10 percent of patients of state narcological clinics remain in remission a year after their treatment.⁹ Indeed, Human Rights Watch interviewed drug users in each of the regions visited for this report who told us that they had gone back to using drugs within days of their release from the detoxification clinic. Using other measures of treatment effectiveness, such as the treatment system’s ability to recruit patients and retain them for a length of time adequate for appropriate treatment, the Russian system fares equally poorly.

Some narcological clinics in Russia also appear to routinely violate the privacy rights of those who try to access them. Governments and their agents are required to observe confidentiality of medical information. It appears, however, that some state narcological clinics in Russia share information on patients who are on the state drug user registry with law enforcement and other government agencies. The Penza Anti-AIDS Foundation survey found that respondents in many of the 10 regions surveyed believed that narcological clinics had shared information on them with others, mostly law enforcement agencies.¹⁰ The routine sharing of medical information of drug users violates the acceptability component of the right to health, and the right to privacy protected under the European Convention on Human Rights, to which Russia is a party.

Human Rights Watch also found that Russia imposes unnecessary restrictions on the rights of people on the drug user registry, such as the right to obtain a driver’s license or hold certain jobs, and thereby violates the principle of non-discrimination. While the rationale behind these restrictions—public safety—may in principle appear to be legitimate, the restrictions are imposed selectively only on those drug users who have to avail of free treatment at state clinics because they cannot afford to pay for treatment services. Whether a patient can pay for services is not a legitimate criterion on which to determine that private information about them should be retained on a registry and be used to restrict certain civil rights. Furthermore, the restrictions are disproportionate as they are imposed for a five-year period without any assessment whether there is a need to impose them on the individual in question or any periodic review to determine whether that need continues to exist.

The close links between injection drug use and HIV infection add extra urgency to the need for effective drug dependence treatment. Injection drug users make up an estimated 65 to 80 percent of all persons living with HIV in Russia and around 10 percent of injection drug users in Russia are HIV-positive. Effective drug dependence treatment has been shown to help reduce HIV infections as patients may either stop using drugs altogether or may adopt less risky injection behavior. Today, as Russia is rapidly expanding access to antiretroviral (ARV) treatment for people living with HIV, effective drug treatment programs, including methadone maintenance therapy and drug-free programs, could play an important role in aiding drug users in accessing and adhering to ARV treatment. If Russia does not take steps to address the problems of its drug dependence treatment system, it runs the risk of continued and increasing spread of HIV, and even drug resistant HIV strains, due to lack of access by drug users to ARV and their suboptimal adherence due to poor quality drug dependence treatment programs.

Russia needs to take urgent steps to address the various failings identified in this report, and reform its drug dependence treatment system in accordance with the findings of scientific evidence. Human Rights Watch makes the following key recommendations (detailed recommendations are set out in Chapter V):

Key Recommendations to the Government of Russia

Immediately lift the ban on the medical use of methadone and buprenorphine in the treatment of drug dependence and introduce maintenance therapy programs.

Integrate evidence-based drug treatment policies into the drug treatment system.

Adopt and fund a federal plan aimed at increasing the availability of rehabilitation treatment by opening new rehabilitation programs and centers in regions that do not currently have any. This plan should have a clear timeline and benchmarks for implementation, and should prioritize regions and towns on the basis of need.

Take steps to ensure drug users can enter treatment without delay. This should include measures to remove arbitrary requirements to present certificates on various health conditions upon admission, and steps to minimize, to the extent possible, waiting lists for admission.

Provide adequate funding to narcological clinics and cease out-of-pocket charges for medications that should be provided free of charge.

Reform the detoxification treatment protocol to end overmedication of patients and introduce clear guidance on psychosocial interventions aimed at patient retention.

Take steps to ensure all patients in detoxification receive proper counseling on HIV and other diseases that are prevalent among drug users.

Take active steps to counter distrust toward state narcological clinics among drug users. These should include the adoption of a patient bill of rights, clear guidelines on treatment options and costs, and steps to root out corrupt practices by clinic doctors.

Reform the drug user registry to remove blanket restrictions on rights of people on the registry.

Take steps to ensure respect for confidentiality of medical information.

Methods

This report is based on information collected during several field visits to Russia between January and April 2007. Over the course of a total of four weeks in the field, a Human Rights Watch researcher and a consultant conducted detailed interviews with about 60 injection drug users, at least a dozen of whom were living with HIV/AIDS. Almost all were between 20 and 40 years of age, and a quarter were women. These interviews took place in Kazan (Republic of Tatarstan), Kaliningrad, Penza, and Kuznetsk (Penza province). In July 2007 the consultant conducted a number of interviews with drug users in St. Petersburg. These cities were chosen because they all have a serious illicit drug use problem but have varying levels of HIV prevalence among drug users and of harm reduction services availability.

Interviews were conducted in private, were semi-structured and covered a number of topics related to illicit drug use, drug dependence treatment experiences, and care and treatment for HIV (where relevant). Interviews were conducted predominantly in nongovernmental organization (NGO) and government offices, at harm reduction worksites, and at hospitals. Interviewees were identified largely with the assistance of Russian NGOs providing services to injecting drug users and people living with HIV/AIDS. Some were specifically asked by NGOs to speak to the researchers while others happened to visit the site where the researchers were at work. These interviewees may therefore have had greater access to drug dependence treatment, harm reduction, and HIV/AIDS services than the general population of injecting drug users. The identity of these interviewees has been disguised with pseudonyms, and in some cases certain other identifying information has been withheld, to protect their privacy and safety. Before the interview, interviewees were told of the purpose of the interview, informed what kinds of issues would be covered, and asked if they wanted to proceed. No incentives were offered or provided to persons interviewed.

The Human Rights Watch researcher is a fluent Russian speaker with years of experience working in Russia. The consultant is an HIV treatment peer counselor in St. Petersburg and a native Russian speaker.

Human Rights Watch also interviewed Russia’s chief narcologist, and the chief narcologists for the Republic of Tatarstan and Kaliningrad region; the chief narcologist in Penza declined to meet with Human Rights Watch. In Kuznetsk, Human Rights Watch interviewed the head doctor and the psychologist of the local narcological clinic. Human Rights Watch also interviewed doctors at the AIDS centers and representatives of NGOs in each of the cities visited. We also interviewed more than a dozen representatives of NGOs in Moscow and other cities in Russia, as well as several international experts, about Russia’s drug dependence treatment system. We also conducted extensive literature study on the topic of drug dependence treatment, and consulted with various international experts on it.

All documents cited in the report are either publicly available or on file with Human Rights Watch.

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