Illicit Drug Use and Drug Policy in Russia
Illicit drugs, which had been fairly rare in the Soviet Union, made a decisive entry onto the Russian scene in the 1990s. At a time of opening international borders and widespread social upheaval caused by political and economic transformation, rapidly increasing numbers of people, mostly young, began using drugs. Today, estimates for the number of drug users range from 3 to 6 million people,11 in Russias total population of about 143 million. In 2004 the head of the Federal Narcotics Control Service (FNCS) stated that between 4 and 5 million people regularly use drugs.12 A 2003 country profile by the United Nations Office for Drugs and Crime (UNODC) estimated that about 2.4 percent of the total adult population uses drugs.13
The vast majority of drug users in Russia use drugs intravenously.14 Most people use heroin, although khanka, an opiate produced from poppy straw, and vint, a home-made amphetamine, are also used.15 According to the International Narcotics Control Board (INCB), Russia is becoming the largest heroin market in Europethe INCB estimated the number of heroin users at close to one million people in 2004with that number continuing to increase.16 Although the number of drug users appears to have stabilized somewhat in recent years, Russias National Research Institute for Substance Abuse reported a considerable increase (16.3 percent) in the number of people newly diagnosed with drug dependence in 2005, for the first time in five years.17
The drug use explosion of the late 1990s was accompanied by a rapid increase in the number of HIV infections. Due to poor knowledge of HIV and the frequent joint use of injecting equipment, HIV spread rapidly. In the years between 1995 and 2001 the rate of new infection doubled every six to twelve months.18 By mid-2006 almost one million people were believed to be HIV-positive, the vast majority of them infected through drug use.19 Rates of HIV infection among drug users vary considerably across Russia. According to National Research Institute for Substance Abuse studies, 9.3 percent of injection drug users who are registered with state narcological clinics were HIV-positive in 2005.20 In some Russian cities studies have found considerably higher prevalence rates. For example, UNAIDS cites studies that found that 30 percent of injection drug users in St. Petersburg were HIV-positive and 12 to 15 percent in Cherepovets and Veliky Novgorod.21
In response to the illicit drug use problem, Russian policy makers and law enforcement agencies have enacted various measures aimed at interrupting drug trafficking, bringing drug traffickers and dealers to justice, incarcerating drug users, and preventing the onset of drug use. Although a concept for illicit drug policies adopted in 1993 by the Supreme Soviet, the parliament at that time, had called for an approach that carefully balanced law enforcement action with public health and prevention measures, the policies that were enacted have often strongly emphasized law enforcement,22 at the expense of public health responses.
Up until 2004, the criminalization of possession of very small amounts of drugs led to widespread preying by police on drug users rather than on dealers, driving drug users underground and away from healthcare services. Law enforcement agencies efforts to counter incitement of drug usea criminal offense under Russian lawhas interfered with attempts to introduce harm reduction and needle exchange programs aimed at educating drug users on HIV, hepatitis, and other health risks related to drug use and helping them protect their health.
Over-incarceration of Drug Users
From 1996 to 2004, possession of very small amounts of heroinas little as 0.005 gram (about one hundredth of an average daily dose)was a criminal offense punishable by imprisonment for five to seven years.23 Absurdly, a drug-dependent person apprehended at the time in possession of one dose of heroin and a drug dealer caught with 100 kilograms could both be charged under the provision of the criminal code for possession of especially large amounts of illicit drugs. During this period, many drug users were prosecuted for possession of small amounts of drugs that were meant for personal use. Many ended up going to jail for lengthy prison terms. In its 2004 book on illicit drug policies and the global HIV epidemic, the International Harm Reduction Development Program of the Open Society Institute concluded,
The widespread practice of targeting drug users for possession of small amounts of drugs has been harmful to public health efforts. As Human Rights Watch concluded in a 2004 study on HIV in Russia, the practice had created a climate of fear for drug users:
In recent years there have been some attempts to move away from pursuing drug users. In May 2004 the Russian government decriminalized possession of small amount of drugs; for example, possession of a gram of heroin or less became a misdemeanor rather than a criminal offense. This resulted in some 40,000 drug users being released from prison or having their sentences reduced.26 Lev Levinson of the Institute for Human Rights and the Public Expertise Institute estimates that in 2004 and 2005 at least 60,000 drug users were spared criminal prosecution and possible prison time due to these changes.27
In February 2006 the Russian government partially reversed the reforms of May 2004. Possession of more than one-half of a gram of heroin is now considered a criminal offense. According to Levinson, the number of criminal prosecutions for possession of illicit drugs has risen sharply since February 2006, with 30,000 more people facing prosecution for the crime in 2006 than in 2005.28
Harm Reduction Programs
Despite their proven effectiveness at slowing the spread of HIV, and their other health benefits to drug users, harm reduction programsand needle exchange in particularcontinue to be controversial in Russia. Their exact legal position will remain unclear until a joint position of the Ministry of Health and Social Development and the FNCS, which has been in the making for years, is adopted. The lack of a clear official position in support of harm reduction programs leads to continuous insecurity for those programs that exist, and widely varying views on harm reduction programs by regional administrations, some of which refuse to allow them to work on their territory.
When harm reduction programs were first introduced in Russia in the mid-1990s, law enforcement agencies generally regarded them with suspicion. As Lev Levinson points out in an article about the legal status of harm reduction programs, law enforcement agencies regularly expressed the opinion that syringes ought to be confiscated rather than distributed since they represent paraphernalia for illegal activity and that an invitation to use sterile syringes may be considered an act of encouraging someone to use drugs or promoting drugs, which constitutes a criminal offense under article 230 of the Russian criminal code.29
In 2003 the Russian State Duma (parliament) adopted a series of amendments to the Russian criminal code that included an annotation to article 230 that specified that promotion of the use of relevant tools and equipment necessary for the use of narcotic and psychoactive substances, aimed at prevention of HIV infection and other dangerous diseases did not violate the article provided that it is implemented with the consent of relevant health and law enforcement authorities.30
The government requestedthe Ministry of Health and Social Development and the Federal Narcotics Control Service to develop regulations for harm reduction programs. Initially it appeared that the authorities would adopt these regulations swiftly. In 2004 the Ministry of Health and Social Development developed a draft with input from the FNCS and various nongovernmental organizations. However, the FNCS then stalled on approving the draft and, in late 2006, produced its own draft, which, if adopted, would effectively make it impossible to operate needle exchange programs.31 At this writing, the government had not approved either draft.
Due to this official wrangling over harm reduction programs, considerable discrepancies in policies toward harm reduction services across Russia persist. In some regions, harm reduction programs cannot operate syringe exchange points at all as local authorities and the narcotics control services oppose them, while in others local authorities actively support them. The discrepancies were clear in the cities visited for research for this report. While Kazan has a strong needle exchange program that enjoys support of the local authorities, Kaliningrad has no harm reduction program at all. A spokesperson for the narcotics control service in Kaliningrad left no doubt in a meeting with Human Rights Watch that his agency would not tolerate any attempt to operate a needle exchange program in the city.32 In Penza, the operation of the local harm reduction program was disrupted in 2006 because local authorities, apparently under pressure of the narcotics control service, were unwilling to provide it with office space.33
The shifting position of narcotics control services on needle exchange programs in several of the regions participating in the Globus project also illustrates the insecurity that harm reduction programs in Russia face. The Global Fund to Fight HIV, Tuberculosis and Malaria awarded a large grant to a coalition of nongovernmental organizations, led by the Open Health Institute, to implement a projectthe Globus projecton HIV prevention, care, and treatment between 2004 and 2009. As a condition for participation in the project, regional narcotics control services in the 10 regions had to provide support letters for harm reduction programs, including needle exchange. In several of the regions that participate in the project, narcotic drug control services have since withdrawn their letters of support, apparently under pressure of the FNCS.34 Although the withdrawal of these letters has not had an impact on the operation of the harm reduction programs in those regions, it did sent a clear signal of ambivalence.35
Despite such official ambivalence, about 60 harm reduction programs were active in Russia at this writing. In 2006 the Global Fund awarded a 10.1 million (approximately US$13 million) grant to the Russian Harm Reduction Network to support and expand harm reduction services in 33 cities in Russia. Two other Global Fund grants, one to the Globus project and one to the Russian Health Care Foundation, also support harm reduction programs. In 2006 the Russian federal government also funded some harm reduction programs through the national health project.
Russias Drug Dependence Treatment System
Russia has a predominantly state-run drug dependence treatment system that has traditionally been highly centralized. As a result, the basic drug dependence healthcare infrastructure and treatment approach a drug user encounters when he or she seeks treatment today look very much the same whether the user is in Kazan, Kaliningrad, or Penza. The basic elements of this system go back to the now defunct Soviet-era alcohol and drug dependence treatment system, even if some of the defining features of that system no longer exist. There is, however, increasing regional differentiation now that Russia is in the process of decentralizing its healthcare system. As the healthcare infrastructure is now largely paid for from local budgets, regional wealth and commitment to drug dependence treatment are becoming key determinants in the availability and accessibility of various treatment services.
The Soviet Alcohol and Drug Dependence Treatment System
The Soviet authorities treated drug dependence, a fairly rare condition, the same way as alcoholism, which was far more widespread. The response to both problems was centered on the notion that citizens of the Soviet Union must treat their health with care, and that alcoholism and drug dependence were diseases posing a threat to surrounding people.36
People who were diagnosed with either condition were expected to undergo treatment and then refrain from further use of illicit drugs or abuse of alcohol. Treatment consisted of a detoxification course followed by regular outpatient observation with a narcologist for a period of five years. Those drug- or alcohol-dependent people who refused treatment or continued to abuse illicit drugs or alcohol risked being committed to special work camps for drug users and alcoholics, known in Russia as LTPs (lechebno-trudovye profilaktorii), for a period of six months to two years, where they were subjected to reeducation through labor.37 More than two million people, the vast majority of them alcoholics, went through these camps in the 1970s and 1980s.38
In order to ensure that individuals dependent on drugs or alcohol were indeed refraining from further use of illicit drugs or abuse of alcohol, they were essentially placed under surveillance by state substance abuse clinics. Doctors at these clinics entered them into a special registry. People on this registry were expected to make regular follow-up visits to narcologists over the course of five years (three years for alcohol-dependent persons). After five years of abstinenceand at least 30 visitsdoctors would take a drug user off the registry.39 As explained below, a single relapse, however, could reset the follow-up procedure. The registry also served as the basis for restricting certain rights of drug- and alcohol-dependent persons, including the right to obtain a drivers license and the right to hold certain jobs.
Doctors at substance abuse clinics cooperated with other state bodies, including law enforcement agencies, in enforcing state policies toward drug users. Laws on confidentiality of medical information explicitly stipulated that information on drug- and alcohol-dependent persons should only be treated confidentially if the persons involved were taking a critical attitude to their condition, were firmly committed to medical treatment and diligently carried out all medical prescriptions.40 Information on persons on the registry was routinely shared with law enforcement agencies.
Drug- and alcohol-dependent persons who refused treatment or continued to use drugs or alcohol were essentially treated as criminal offenders. In fact, during proceedings to commit them to LTPs their legal position was considerably worse than that of criminal defendants: Soviet law provided for simplified proceedings in such cases and court rulings were not subject to appeal. The legal regime at LTPs, which were run by the ministry that also ran the prison system, resembled that in penal colonies.41 Escapes from LTPs were criminal offenses and carried a punishment of up to one years imprisonment.42 In 1987, during an anti-alcohol campaign, the Soviet Union made the use of illicit drugs a criminal offense and misdemeanor.43
Changes in early 1990s
In the early 1990s, as the Soviet Union fell apart and the new Russian leadership embarked on a new course, policies toward drug dependence underwent a number of important changes. In 1990 the Committee for Constitutional Supervision of the USSR, a body with Constitutional Court-like functions, declared the LTPs and criminal liability for illicit drug use unconstitutional. It observed that committing drug- and alcohol-dependent persons to LTPs constituted isolation of the person from society for a considerable period of time, which makes this measure similar to that of the criminal punishment deprivation of freedom and that treatment of people who are ill with alcohol or drug dependence who have not committed offenses should be conducted on a voluntary basis in medical, not penal institutions.44
In 1993 Russia adopted a law that set out the fundamental principles of legislation in the field of health care. This law guaranteed confidentiality of medical information for all patients, established the principle of voluntary treatment based on informed consent, and banned all forms of discrimination on the ground of a health condition.45 A 1992 law on psychiatric care, which has also been applied to drug dependence, also enumerates these rights.46
Also in 1993, as mentioned above, Russias Supreme Soviet adopted a new concept policy on illicit drug use that proposed a significant shift away from the Soviet-era approach in favor of an approach that balanced law enforcement and public health interventions. It called for a mixture of law enforcement and educational measures, emphasizing prevention and efforts to change social and cultural stereotypes. It also called for the establishment of a state-run institution that would provide social support and rehabilitation for drug-dependent persons. It further recommended that the persons who had committed minor drug-related offences be subjected to medical treatment, rather than to punishment.47 The document was not a law but served as a declaration of intentions. Illicit drug policies have in practice not followed the spirit of this concept policy; this is best illustrated with the criminalization of possession of very small doses of drugs, discussed above.
Russias Contemporary Drug Dependence Treatment System
Drug users in Russia who wish to seek medical treatment can do so through the state drug dependence treatment system, which offers them detoxification services and, in some regions, rehabilitation treatment. Today, treatment is mostly voluntary, although in certain, limited circumstances drug users can also be forcibly committed to treatment.48
System of state clinics
The state is the primary provider of drug dependence treatment in Russia, although some private treatment facilities do exist (see below). In 2005 the state treatment infrastructure consisted of 192 so-called narcological dispensaries, inpatient facilities with a cumulative total of 28,200 beds for alcohol and drug detoxification and care for complications arising from the misuse of alcohol and drugs, and 1,975 narcological cabinets, outpatient facilities that mostly cater to alcohol-dependent patients. That year, the system provided services to 717,000 patients, including approximately 70,000 drug users.49
State rehabilitation programs are a relatively new phenomenon; a government program to create such centers began only in 2000. In 2006 rehabilitation centers existed in 26 regions.50 The state narcological services currently offer about 1,100 beds for free rehabilitation treatment across Russia, according to Russias chief narcologist, Nikolai Ivanets.51 In a meeting with Human Rights Watch Dr. Ivanets, who is also the head of the National Research Center for Substance Abuse, said that great importance is accorded to the further development and improvement of rehabilitation programs.52
State clinics offer drug-free treatment programs for opioid dependence that are aimed at immediate and complete abstinence. Official treatment protocols identify three phases of treatment: the detoxification phase, a post-abstinent phase that immediately follows detoxification, and the remission phase.53
The detoxification phase involves inpatient treatment ranging from 3 to 12 days, depending on the level of drug dependence of the patient. The treatment protocols recommend the use of a range of medications including pharmacotherapy to suppress withdrawal symptoms, tranquillizers and sleeping pills, antipsychotics, anticonvulsants, and others. Treatment heavily relies on these medications, with most patients getting a cocktail of drugs. People interviewed for this report who went through detoxification treatment remarked that they were in a coma-like sleep for the first half of their treatment and remained heavily tranquillized for the remainder of it. Outpatient detoxification services for drug users do not formally exist, although doctors at narcological clinics in many regions do offer such care unofficially (and for payment). The treatment protocol for the lightest form of dependence also recommends suggestive psychotherapy.54
The treatment protocol for the second phase recommends a further 21 days of inpatient treatment, although it states that outpatient treatment is also a possibility. The protocol recommends a variety of medications for symptoms related to feelings of depression, related behavior, and urges to use narcotics. It also recommends psychotherapy, massage, and acupuncture.
For the final remission phase, the treatment protocol recommends six to eight months of outpatient treatment, during which the patient continues to receive antidepressants, antipsychotics, and stimulants, and undergoes blood and urine tests every three to four weeks. The protocol also recommends psychotherapy for this period but does not provide any detail on the type of psychotherapy or its frequency.
Narcological clinics do not offer opioid maintenance therapy for drug users. As already noted, the use of methadone or buprenorphine for treating drug-dependent persons is prohibited by law.55
Some narcological clinics host drug user self-help groups on their premises. However, Natalia Bobrova of the Department of Epidemiology and Public Health at University College London and several colleagues who have conducted extensive research on drug use, drug dependence, and HIV in Russia, observe that Narcotics Anonymous meetings are generally available in cities only.56 Of the regions visited for this report, several strong Narcotics Anonymous groups exist in Kazan, one hosted by a narcological clinic and one by a local NGO, with meetings most days of the week and attendance varying from 30 to 70 people per meeting; a much smaller one exists in Kaliningrad. No such groups exist in Penza and Kuznetsk although one had existed in the latter city when it hosted a now-defunct drug dependence rehabilitation program a number of years ago.
Drug user registration and confidentiality
The drug user registry continues to exist as in Soviet times, with some modifications. Drug-dependent persons who seek treatment at state clinics are, in principle, put on the registry. 57 In many regions, however, drug users can pay for services they receive at state clinics in order to avoid the registry (see also below). Some individual narcologists will also give patients free outpatient treatment without registering them.
Registered drug users are expected to pay regular follow-up visits with their treating doctor over the course of at least five years, generally making no less than 30 such visits.58 During these follow-up visits, narcologists may require urine or other tests to establish whether the patient remains abstinent. A patient can be taken off the registry after five years if he or she carried out all orders [naznachenii] of the treating doctor, appeared at substance abuse institutions in time, and has achieved, after treatment, a firm, objectively confirmed remission.59 In case a drug user relapses at any point in this period, the five-year period may be reset. Most drug users interviewed for this report who were on the drug user registry said that they do not go to the narcological clinic for follow-up appointments, meaning that they will never be taken off the registry. Not surprisingly, therefore, the number of people taken off the registry every year due to completion of five years of observation is small. Nikolai Ivanets, Russias chief narcologist, told Human Rights Watch that more people are taken off the registry because they die than because of recovery.60 In 2005 a total of 343,500 drug-dependent persons were on the drug user registry, with 24,390 people being newly registered that year.61
Legal provisions on confidentiality of information in the registry have improved considerably since Soviet years, but some state clinics and doctors still appear to routinely share such information on patients with law enforcement agencies. Legislation on health care now recognizes the confidentiality of medical information and allows for its disclosure only in certain cases. However, among others, it stipulates that medical doctors may disclose medical information if there is ground to believe that the damage to the health of a citizen was inflicted as a result of unlawful activity.62 As the use of illicit drugs is a misdemeanor under Russian law and thus unlawful, this formally allows medical doctors to report drug users who seek treatment to law enforcement agencies.63 The prosecutors office and courts may also seek information on a specific individual in the context of a criminal investigation.64
It appears that in some regions regulations continue to exist that oblige doctors at narcological clinics to share information on drug users on the registry with law enforcement. This is, for example, the case in Moscow, where a mayoral order of 1998 instructs the city police and healthcare department to create a system to exchange information about persons who engage in non-medical use of narcotics.65 However, Lev Levinson has told Human Rights Watch that narcologists in Moscow had insisted to him that the order is no longer implemented.66
(The FNCS has developed a nation-wide database on illicit-drug-related issues. Some newspapers suggested in April 2007 that this database would also include identifying information on individual patients. However, a federal regulation stipulates that only statistical information about users who seek help from narcological clinics is included.67)
Doctors at narcological clinics in Kazan, Kaliningrad, and Kuznetsk told Human Rights Watch that confidentiality is strictly observed. However, many drug users maintain that breaches of confidentiality, to law enforcement agencies, relatives, and employers, do occur regularly. For example, a survey of almost 1,000 drug users in 10 regions conducted by the Penza Anti-AIDS Foundation found that about one-third of all drug users believed that narcologists had breached their confidentiality to law enforcement structures or to relatives. The study found considerable regional differences, with 67.5 percent of people surveyed in Penza reporting believed breaches of confidentiality, almost all to law enforcement agencies, while only 8.3 percent of people surveyed in Orenburg said narcological clinics had breached their confidentiality.68
Cost of treatment in state clinics
Russias constitution requires that medical treatment at state and municipal clinics be offered free of charge.69 State-run narcological clinics accordingly offer treatment free of charge. However, free treatment is not always actually cost-free. In both Kaliningrad and Penza drug users told us that they were charged out-of-pocket fees for medications or had to bring their own. As Bobrova and others observe, the failure to provide stable and adequate funding for narcological clinics has led to a widespread practice of assessing out-of-pocket fees, which frequently include the costs of medication.70
In recent years state narcological clinics have become increasingly commercialized as they have struggled financially due to often insufficient funding from local and federal budgets. This has led to clinics encouraging, or even pushing, drug users to pay for their treatment. In many regions patients who pay for their treatment can count on better conditions than those who make use of free services. Some clinics, like the ones in Kaliningrad and Kazan, have created special wards for paying patients.
These trends are not unique to the narcological system. There is generally a wide gap between the constitutional guarantees of free healthcare services for all and the reality. Patients in many parts of the healthcare system cannot get good healthcare services for free, are assessed out-of-pocket charges, and are pushed toward paid services.
Our research and that of others has found that most drug users are highly apprehensive about being formally registered as a drug user.71 In some regions, doctors at narcological clinics use the fact of the drug user registry as an indirect way of pushing drug users to pay for their treatment, as drug users are only offered free treatment if they agree to be entered onto the registry (see also below). Inna Vyshemirskaya, a sociologist and lead Russian researcher in a 2006 assessment of health problems related to illicit drug use and HIV/AIDS in Kaliningrad, explained how this is done in Kaliningrad:72
Waiting lists for free treatment, which exist in some regions, also push drug users toward paid services. Human Rights Watch interviewed various drug users who said that they had paid for their treatment so they would not have to wait.
The cost of paid treatment varies from region to region, and sometimes within regions depending on desired treatment conditions. Inhabitants of Tatarstan pay 7,500 rubles (approximately US$300) for a 10-day detoxification course; people from other regions pay 12,000 rubles (about $480) for the same course. In Kaliningrad local experts estimated that drug users paid between 1,800 and 3,000 rubles (about $72 and $120) per day for detoxification treatment; in Penza, paid treatment costs about 1,200 rubles (about $48) per day; and paid rehabilitation treatment in Kazan costs around 500 rubles (about $20) per day.
Drug dependence treatment is not covered by state health insurance policies in most parts of Russia.74
Private drug dependence treatment clinics
There is a small but growing number of private drug dependence clinics in Russia that offer rehabilitation services. Russian law bans private clinics from providing medicated detoxification services but allows them to engage in rehabilitation.75 Private clinics are mostly commercially run or are faith-based. A number of private treatment centers exist in the regions visited for research on this report: In Kazan a nongovernmental organization called Roza Vetrov offers a free three-month outpatient rehabilitation program that is based on the 12-step model; in Kaliningrad province two private rehabilitation centers currently offer paid long-term inpatient treatment based on the Polish Monar system and two faith-based rehabilitation centers linked to protestant churches offer treatment for a minimal fee or free of charge for those who cannot afford the fee.
Various studies suggest that there is considerable treatment demand for drug dependence treatment in Russia. The Penza Anti-AIDS Foundation study of almost 1,000 drug users in 10 regions of Russia found that only 7.3 percent of male drug users and 4.9 percent of female drug users it surveyed had never tried to stop using drugs. A total of 63.9 percent of drug users surveyed had made five or more attempts at quitting drugs, whereas only 6.3 percent had made just one attempt. The study found a direct correlation between the number of years a person had used drugs and the number of attempts the person had made to stop using; the longer a respondent used drugs, the more likely he or she was to have made attempts to stop using drugs and the larger the number of such attempts.76
Almost every drug user Human Rights Watch interviewed for this report said that he or she wished to stop using drugs. Most had made repeated attempts, either at home or in a healthcare setting, to do so. One drug user from Kazan who had made repeated attempts at home said that he would very much like to overcome his drug dependence but has not been able to so far. He said that he sometimes manages to stop using for a month or two but then relapses: It is just so difficult to get out of that swamp.77 A woman from Penza broke out in tears when she told Human Rights Watch that she had relapsed after years of abstinence when she learned that she was HIV infected:
Despite high treatment demand, only a small percentage of drug users actually make use of state drug dependence treatment services. A 2003 Ministry of Health treatment protocol for rehabilitation of persons dependent on drugs cites an estimate of the National Research Institute on Substance Abuse that one in every seven drug users seeks treatment at state narcological clinics.79 In 2005 UNODC estimated that only about one in every ten drug users in Russia reaches drug abuse treatment services.80 That year about 70,000 people sought treatment for drug dependence at state clinics.
Uptake of rehabilitation treatment is even lower. Narcologists in Kazan, Kaliningrad, and Kuznetsk told Human Rights Watch that few drug users agree to enter into rehabilitation after detoxification treatment. The chief narcologist in Tatarstan stated that about 5 to 8 percent of patients in his region continue with rehabilitation after detoxification services, despite the availability of several rehabilitation programs.81 Nikolai Ivanets, Russias chief narcologist, told Human Rights Watch that numerous rehabilitation beds are unoccupied because, in his opinion, many drug users simply dont want to be treated. He suggested that the reason why many drug users criticize the narcological services as ineffective was to justify their own lack of will to get treatment.82 As will be explained below (Failure to Facilitate Patient Retention), the failure of narcological clinics to counsel patients on the importance of rehabilitation treatment and prepare them for such treatment is a key reason for this low uptake.
Russias drug dependence treatment system uses a highly rigid system for assessing the effectiveness of its services: it looks at the state of remission of registered patients one year after they entered detoxification treatment. If the patient is in remission and no relapses have been registered, treatment is considered to have been successful. In other cases, it is considered to have failed. Other factors, like the percentage of patients who continue with rehabilitation treatment after detoxification, the average length of patients stay in treatment, the frequency of relapses, the amount of time that passes before a relapsing drug user seeks help again, changes in the social situation of the patient, or the patients self-esteem, are not formally considered.83
Two monographs on drug dependence treatment by staff of the National Research Institute for Substance Abuse state that between 5 and 9 percent of patients remained abstinent a year after receiving treatment.84 The Penza Anti-AIDS Foundation survey found that about 90 percent of drug users surveyed said that they had returned to drug use within a year of receiving detoxification treatment.85 Seven percent reported that they never really stopped using drugs as they continued to use them in the detoxification clinic; 35 percent said that they started using again within a week of finishing detoxification treatment; and another 17 percent said they resumed drug use within one month.86
Russian drug dependence treatment experts recognize that detoxification without rehabilitation rarely leads to lasting abstinence. For example, a 2003 Ministry of Health treatment protocol for rehabilitation of persons dependent on drugs states, With medical [detoxification] interventions alone success can only be achieved among three to five percent of those with drug dependence disease.87
Most drug dependence treatment systems use a number of other indicators of treatment effectiveness along with abstinence. These include the percentage of patients who continue with rehabilitation treatment after detoxification and the average amount of time patients stay in treatment. If judged by these indicators, Russias treatment system also fares poorly. As was mentioned above, only a small percentage of drug users who go through detoxification continue with rehabilitation treatment, resulting in an average length of stay in treatment of only a few weeks for most drug users. Scientific research indicates that for most patients the threshold of significant improvement is reached at about three months in treatment (this and other best practices are discussed in the next chapter).88
11 United Nations Office on Drugs and Crime (UNODC), Illicit Drug Trends in the Russian Federation 2005, 2006, www.unodc.org/pdf/russia/Publications/drug%20trends%202005_eng.pdf (accessed August 28, 2007), p. 11.
12 US Bureau for International Narcotics and Law Enforcement Affairs,International Narcotics Control Strategy Report 2006, March 2006, http://www.state.gov/p/inl/rls/nrcrpt/2006/ (accessed August 28, 2007).
13 UNODC, Russian Federation: Country profile, 2003, as cited in Natalie Bobrova, Tim Rhodes, Robert Power, Ron Alcorn, Elena Neifeld, Nikolai Krasiukov, Natalia Latyshevskaya, and Svetlana Maksimova, Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities. Drug and Alcohol Dependence, 82 Supplement 1 (2006), S57-63.
14 UNODC, Illicit Drug Trends in the Russian Federation 2005, p. 11.
15 Eighty-five percent of the 343,500 drug-dependent people registered with Russias alcohol and drug treatment services in 2005 were addicted to heroin. Nikolai Ivanets, Drug Addiction Today, Prevention, Treatment, Rehabilitation (powerpoint presentation), undated. A copy of the presentation was provided to Human Rights Watch on March 7, 2007, by Mr. Ivanets.
16 International Narcotics Control Board (INCB), Annual Report 2004, E/INCB/2004/1, http://www.incb.org/incb/annual_report_2004.html (accessed August 28, 2007), p. 72.
17 E.A. Koshkina and V.V. Kirzhanova, Specifics of the spread of substance abuse disorders in the Russian Federation in 2005 (Osobennosti rasprostranennosti narkologicheskikh rasstroistv v Rossiiskoi Federatsii v 2005 g.), Psykhiatria i psykhofarmokoterapia (Psychiatry and psychopharmacotherapy), vol. 9/N1/2007, http://www.consilium-medicum.com/media/psycho/07_01/18.shtml (accessed July 9, 2007).
18 United Nations Development Programme (UNDP), Reversing the Epidemic: Facts and Policy Options (HIV/AIDS in Eastern Europe and the Commonwealth of Independent States), ISBN 92-1-126162-7, February 17, 2004, http://rbec.undp.org/hiv/?english (accessed October 1, 2007).
19 United Nations Joint Programme on HIV/AIDS (UNAIDS), AIDS Epidemic Update: Eastern Europe and Central Asia, Geneva, 2006, www.unaids.org/epi/2005/doc/EPIupdate2005_pdf_en/Epi05_07_en.pdf (accessed October 1, 2007), p. 39.
20 Ivanets, Drug Addiction Today, Prevention, Treatment, Rehabilitation.
21 UNAIDS, AIDS Epidemic Update: Eastern Europe and Central Asia, p. 35.
22 Concept of state policy on the control of narcotics in the Russian Federation, as adopted by ruling No. 5494-1 of the Supreme Soviet of the Russian Federation of July 22, 1993.
23 Daniel Wolfe and Kasia Malinowska-Sempruch, Open Society Institute, Illicit Drug Policies and the Global HIV Epidemic: Effects of UN and National Government Approaches, 2004, http://www.soros.org/initiatives/health/focus/ihrd/articles_publications/publications/cnd_20040316 (accessed October 1, 2007), p. 39.
24 Ibid., p. 46.
25 Human Rights Watch, Lessons Not Learned: Human Rights Abuses and HIV/AIDS in the Russian Federation, vol. 16, no. 5 (D), April 2004, http://hrw.org/reports/2004/russia0404/.
26 Lev Levinson, Half a gram and thousands of lives, Russian Harm Reduction Network Newsletter 2006-2007, http://www.harmreduction.ru/files/harm_reduction_russia_2006-2007_eng.pdf (accessed June 27, 2007), pp. 9-11.
28 Human Rights Watch telephone interview with Lev Levinson, Moscow, July 9, 2007.
29 Article 230 of the Russian Criminal Code (Criminal Code of the Russian Federation, June 13, 1996, as amended on December 28, 2004, Chapter 25, Crimes Against Health of the Populace and Social Morality) prohibits the incitement of drug use. Lev Levinson, How to Properly Exchange Needles: The story of how not to develop a methodological guideline, http://www.harmreduction.ru/files/harm_reduction_russia_2006-2007_eng.pdf (accessed June 22, 2007), pp. 12-13.
30 Federal Law no. 162, About amendments and additions to the Criminal Code of the Russian Federation, December 2003.
31 Some of the major problems of the draft include: a ban on mobile needle exchange points; a provision that all needle exchange programs must operate out of state or municipal medical facilities; highly burdensome and expensive procedures for disposing of used needles; and a requirement to use syringes that have been shown to be ineffective in needle exchange programs.
32 Human Rights Watch interview with Mikhail Nechushkin, Kaliningrad, January 29, 2007.
33 Human Rights Watch interview with Sergei Oleinik, Penza, April 11, 2007.
34 The regions covered by the Globus project are: the Republic of Tatarstan, Tver province, the Republic of Buriatia, the city of St. Petersburg, Pskov province, Vologda province, Nizhnii Novgorod province, Tomsk province, Orenburg province, and Krasnoyarsk region.
35 Human Rights Watch email correspondence with Aleksei Bobrik of the Open Health Institute, July 31, 2007.
36 V. Pelipas and I. Solomonidina, The rights of persons addicted to psychoactive substances, in Moscow Helsinki Group, Human Rights and Psychiatry in the Russian Federation, 2004, http://www.mhg.ru/english/3959925 (accessed August 28, 2007).
37 Initially, drug- and alcohol-dependent people could be sent to LTPs only if, in addition to refusing treatment or continuing to abuse substances, they also violated public order, work discipline, and the rules of socialist life. In 1985, however, as part of an anti-alcohol campaign launched by USSR leader Mikhail Gorbachev, refusal to undergo treatment or continued abuse of substances alone became sufficient ground for committing drug- and alcohol-dependent persons to LTPs. See Conclusion of the Committee for Constitutional Supervision of the USSR of 25 October 1990 No. 8 (2-10).
38 V.E. Pelipas, I.O. Solomonidina, M.G. Tsetlin, Forced and Mandatory Treatment of Patients with Substance Abuse Profile. Experience and Perspectives (Prinuditelnoe I obyazatelnoe lechenie bolnykh narkologicheskogo profilia. Opyt I perpsektivy), Moscow, 2005.
39 Order N. 704 of the Ministry of Health of the USSR of 12 September 1988 On the periods of follow-up observation of persons affected by the diseases alcoholism, drug dependence, dependence on toxic substances.
40 Pelipas and Solomonidina, The rights of persons addicted to psychoactive substances.
41 Conclusion of the Committee for Constitutional Supervision of the USSR of 25 October 1990 No. 8 (2-10), on file with Human Rights Watch.
42 Pelipas and Solomonidina, The rights of persons addicted to psychoactive substances.
43 Decree of the Presidium of the Supreme Soviet of the USSR of 22 June 1987 On the introduction of amendments and additions to some legislative acts of the USSR.
44 Conclusion of the Committee for Constitutional Supervision of the USSR of 25 October 1990 No. 8 (2-10).
45 Fundamental Principles of Legislation of the Russian Federation on Public Health of 22 July 1993, Chapters 4 and 6.
46 Law on Psychiatric Care and Guarantees of the Rights of Citizens in its Application of 2 July 1992.
47 Citation in: Natalia Bobrova, Ron Alcorn, Tim Rhodes, Iurii Rughnikov, Elena Neifeld and Robert Power, Injection drug users perceptions of drug treatment services and attitudes toward substitution therapy: A qualitative study in three Russian cities, Journal of Substance Abuse Treatment, available online 17 May 2007 [ http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=17499960&dopt=Citation].
48 These exceptions include: courts can commit people to treatment who have a psychiatric disorder and form a danger to themselves or others; parents are authorized to commit children under 16 years of age to treatment (legislation is currently under discussion about raising that age to 18); a judge who finds a drug-dependent person guilty of a criminal offense but sentences him or her to a non-custodial punishment may order him or her to enter drug dependence treatment (Article 73 of the Criminal Code of the Russian Federation); and prison administrations may require a drug-dependent person who is convicted of a criminal offense and sentenced to a prison term to undergo treatment if a medical commission of the prison system considers that necessary.
49 Bobrova et al., Injection drug users perceptions of drug treatment services and attitudes toward substitution therapy: A qualitative study in three Russian cities, Journal of Substance Abuse Treatment.
50 E.A.Koshkina, V.V. Kirzhanova, and O.V.Sidoriuk, Prevalence of substance-related disorders in the Russian Federation in 2004-2005 (Rasprostranennost narkologicheskikh rasstroistv v Rossijskoi Federatsii v 2004-2005), Moscow, 2006, cited in Bobrova et al., Injection drug users perceptions of drug treatment services and attitudes toward substitution therapy: A qualitative study in three Russian cities, Journal of Substance Abuse Treatment.
51 Ivanets, Drug Addiction Today, Prevention, Treatment, Rehabilitation.
52 Human Rights Watch interview with Nikolai Ivanets, Moscow, March 7, 2007.
53 Order N. 140 of the Ministry of Health of the Russian Federation of 28 April 1998 On the confirmation of standards (model protocols) for the diagnosis and treatment of the narcologically ill.
54 Suggestive or directive psychotherapy utilizes the authority of the therapist to direct the course of the patient's therapy, as contrasted with nondirective psychotherapy.
55 Article 31(6) of the Federal Law On Narcotic Drugs and Psychoactive Substances prohibits the use of narcotic drugs and psychoactive substances in treating drug dependence.
56 Bobrova et al., Injection drug users perceptions of drug treatment services and attitudes toward substitution therapy: A qualitative study in three Russian cities, Journal of Substance Abuse Treatment.
57 Order N. 704 of the Ministry of Health of the Union of Soviet Socialist Republics (USSR) of 12 September 1988 About period of follow-up supervision for those affected by alcoholism, drug dependence, or toxicomania. The order also provides for a risk category for people who use drugs but who are not currently considered to be drug dependent.
58 During the first year they are supposed to visit their narcologist once a month; during the second year once every two months; and during the third, fourth, and fifth years three or four times per year.
59 Order N. 704 of the USSR Ministry of Health About period of follow-up supervision for those affected by alcoholism, drug dependence, or toxicomania
60 Human Rights Watch interview with Nikolai Ivanets, Moscow, March 7, 2007.
61 Ivanets, Drug Addiction Today, Prevention, Treatment, Rehabilitation.
62 Article 61 of theFundamental Principles of Legislation of the Russian Federation on Public Health of 22 July 1993.
63 Article 6.9 of the Code on Administrative Violations of the Russian Federation of 30 December 2001, as amended on 21 March 2005.
64 Article 61 of theFundamental Principles of Legislation of the Russian Federation on Public Health of 22 July 1993.
65 Order of the mayor of Moscow of 1 September 1998 N. 887-PM On the confirmation of the regulation on the interdepartmental council on the fight against unlawful circulation of narcotics in the city of Moscow and the plan of initial measures for year 1998.
66 Human Rights Watch telephone interview with Lev Levinson, July 9, 2007.
67 Regulation N. 31 of the Government of the Russian Federation of 23 January 2006 On the creation, keeping, and use of the single database on issues related to the circulation of narcotic substances, psychotropic substances and their precursors, and also the activities to counter their unlawful circulation.
68 Draft report on the survey by the Penza Anti-AIDS Foundation, on file with Human Rights Watch.
69 Government of Russia, The Constitution of the Russian Federation, adopted and entered into force December 12, 1993, http://www.constitution.ru/en/10003000-01.htm (accessed June 27, 2007), art. 41.
70 Bobrova et al., Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities, Drug and Alcohol Dependence.
71 See, for example, Bobrova et al., Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities, Drug and Alcohol Dependence.
72 This assessment was conducted with support of the US National Institute of Drug Abuse using the Rapid Policy Assessment and Response intervention. Similar interventions were conducted in 2005 and 2006 in Odessa (Ukraine) and Szczecin (Poland). A summary of the research findings can be found at http://www.temple.edu/lawschool/phrhcs/rpar/about/reports.html (accessed September 12, 2007).
73 Human Rights Watch interview withInna Vyshemirskaya and Viktoria Osipenko, Kaliningrad, January 30, 2007.
74 Bobrova and others mention Samara as the only exception. Bobrova et al., Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities, Drug and Alcohol Dependence.
75 Article 55(2) of the 1998 Federal Act on Narcotic Drugs and Psychoactive Substances limits detoxification treatment to state institutions. Private healthcare facilities are allowed to do diagnostics, examinations, consultation, and rehabilitation. Federal Act on Narcotic and Psychotropic Substances (E/NL.1998/66), 8 January 1998.
76 Draft report on the survey by the Penza Anti-AIDS Foundation, on file with Human Rights Watch.
77 Human Rights Watch interview with Igor I., Kazan, January 23, 2007.
78 Human Rights Watch interview with Maria M., Penza, April 11, 2007.
79 Order No. 500 of the Ministry of Health of 22 October 2003, Treatment Protocol: Rehabilitation of Persons with Drug Dependence Disease, Chapter VI.
80 UNODC, Illicit Drug Trends in the Russian Federation 2005.
81 Human Rights Watch interview with Farit Fattakhov, Kazan, January 25, 2007.
82 Human Rights Watch interview with Nikolai Ivanets, Moscow, March 7, 2007.
83 In the United Kingdom, for example, drug treatment services work with a range, or hierarchy of goals of drug treatment. The Independent Expert Working Group report lists these goals as: - reducing health, social, crime and other problems related to drug misuse; - reducing harmful or risky behaviors associated with the misuse of drugs (e.g. sharing injecting equipment); - reducing health, social or other problems not directly attributable to drug misuse; - attaining controlled, non-dependent or non-problematic drug use; - abstinence from main problem drugs; - abstinence from all drugs . It explains that reducing harm from an individuals drug use will be an important element of care, especially during the engagement phase of treatment. The principle of a hierarchy of goals is a useful one in helping patients look at any of their treatment objectives in a systematic manner. Independent Expert Working Group, Drug misuse and dependence guidelines on clinical management: update 2007. Consultation draft June 2007, p. 49.
84 N.N. Ivanets and M.A. Vinnikova, Heroin dependence disease characteristics and treatment of the post-abstinent syndrome (Geroinovaia zavisimost klinika I lechenie postabstinentnogo syndrome (Moscow: Medpraktika-M, 2001); and V.V. Chirko and M.V. Demina, The characteristics of clinical narcology drug dependence and toxicomania: disease characteristics, development, therapy (Ocherki klinicheskoi narkologii narkomanii I toksikonanii: klinika, techenie, terapia) (Moscow: Medpraktika-M, 2002). Both monographs are cited in M. Zobin and E. Egorov, Remission with opioid dependence, published at http://www.narcom.ru/cabinet/online/107.html (accessed July 10, 2007).
85 Draft report on the survey by the Penza Anti-AIDS Foundation, on file with Human Rights Watch.
87 Order No. 500 of Ministry of Health and Social Development of the Russian Federationof 22 October 2003, Treatment Protocol: Rehabilitation of Persons with Drug Dependence Disease.
88 See NIDA, Principles of Drug Addiction Treatment; A Research-Based Guide, principle 5.