Author: Dasha Matyushina, Drug Policy and Human Rights Advisor, EHRA
In my almost twenty years of working in harm reduction I have visited many opioid substitution therapy sites in different countries. One of the first programs I was lucky to see was an OST site in New York. A likeable doctor was enthusiastically telling me about his patients – some of them were allowed to collect a two-week methadone supply because “they worked so hard and could not spare the time to come for therapy more often”. That very week I happened to visit another OST site in New York. I saw a huge queue to an armoured window where methadone was dispensed and a uniformed man with arms at the ready standing behind the queuing people. I just could not grasp the existence of two such absolutely different sites in one city.
Since then I have seen dozens of OST sites and talked to hundreds of their clients. The sites were more or less different but the talks I had all seemed an extension to my very first conversation with a girl client of a New York OST site from so long ago. I came from Russia, the country where OST was non-existent at the time, where people could only hope it would be available at some point, so it was really weird to hear people complaining – like, “I am a regular here but sick of this bloody methadone, no adequate care here, the drug quality is not as it used to be, the opening times suck and they don´t treat us as human beings here”…So I no longer idealized those programs and saw not only their value but also the restrictions they impose on people with opioid addictions.
On my way to Pavlodar I did not expect to see an exemplary OST site – I am aware of the challenges such programs face in Kazakhstan and how hard it was to open and keep sustaining OST sites there. I also know what a „pilot OST site“ really means: minimum clients, maximum rules.
Oxana from the Foundation “Ty ne odin” (“You are not Alone”) and I came to an opioid substitution therapy site at 9 o´clock in the morning. There was a constant flow of people, some stopped to chat with me at the entrance, some passed by with a nod to an acquaintance and paid me no attention, some went away and came back with a coffee. There were too many names to remember. At some point there were only about ten of us left – men and women of different ages, some were with kids in buggies, some people were in wheelchairs themselves. They were talking about how much their lives had changed with the introduction of OST. They were sharing their problems – impossible to go visit people in other cities, hospitals still did not have methadone on stock and one had to come here by taxi practically from intensive care to get some. However, that conversation was different from everything I had heard from hundreds of other OST clients before. These people were absolutely convinced of the necessity of this site, they were in dire need of it and ready to fight for it at all cost. They, the patients, were defending their doctors, explaining to me how vulnerable health care workers were in the face of all sorts of monitoring raids. They knew the OST program inside out – what funding sources covered which costs and which options they would have if the Global Fund withdrew the funding. They know everything because it is their program.
Pavlodar OST site is on the ground floor of the local narcology clinic and occupies a tiny room with a small anteroom with benches for clients to sit and chat. It´s a multi-storied building, the rest of it, as I am told, belongs to an in-patient facility for compulsory treatment. There are about seventy OST clients. Methadone doses are high – 70, 80, 100 mg and more. The same room is used for HIV and TB patients who come for ART and TB treatment. Almost all of the clients either work or study. Most of them have families.
The clients say that not a single program participant “gets extra high” – that would be a breach of the rules and several such slips result in exclusion from the program. The frequent checkups prove – the people on therapy have indeed stopped using street drugs. I must say it is very impressive – the hard proof that OST works towards full abstinence. But what happens to those clients who could not for one reason or another stop using drugs completely or resumed their consumption? If they are excluded from the OST program, do they have a chance to continue on ART or TB treatment? If OST did not succeed in helping them, does it mean they are simply thrown “overboard”, again?
The Pavlodar OST program as well as most other OST programs in EECA and in many other parts of the world is a high threshold program. This means strict admission criteria – one should prove that other addiction therapies failed to work for them many times, bring official confirmation of being infected/non-infected by HIV, hepatitis etc. This means frequent and unannounced urine tests for presence of drugs – and if they prove positive the clients will either be forced to attend additional therapies aimed to stop their drug consumption altogether (this is what they do in the USA and Canada) or they are excluded from the program for “breaking the rules”.
Clients who „break the rules“ may be facing serious, overwhelming problems such as depression, home violence, a life crisis, bad social factors. Such people should have access to low threshold OST programs, so they can go on receiving methadone, ART and TB therapy. Such programs are increasingly popular in Canada, they put forward fewer demands „on admission“, there is no queuing and no waiting lists, more tolerance to relapses. Testing for drugs is done less frequently and the clients are informed beforehand. If the client is found using drugs, no reprisals follow. And such programs that do not aim to stop people from consuming drugs help saving lives, too – and to improve the quality of life as well. A recent Canadian study showed that despite the absence of sanctions in such low threshold programs one sees a steady decline in the usage of street opioids and stimulants. The clients feel supported and see they can be accepted as they are today. Their social environment is gradually changing, bringing changes in their lives as well.
There are no low threshold programs in Kazakhstan to date. They may come. However, the number one priority at the moment is to keep what we already have, which means to get the state allocate funding to the existing high threshold programs. Otherwise hundreds of people and their families will be thrown overboard.