“I had to abandon home, family and friends to a place where nobody was waiting for me.”
Former injectable drug-user Ivan spoke to me in Ukraine’s capital of Kyiv in 2014.
Eloquent and talkative, the mid-sized 28 year-old sound technician was a little dishevelled with long hair, stubble and a thick woolen jumper, resembling a roadie for a 90s Americana rock band.
He admitted he was open, almost too open, to speak about his addiction.
“I can talk someone to death if given the chance,” he added.
Until Spring 2014 Ivan lived in Crimea, where he was taking Opioid Substitution Therapy (OST) drug buprenorphine. This medication regulated his life, helped him hold down a job and broke his link to a lifestyle of injecting narcotics and stimulants up to 15 times per day.
But when the Russians seized the peninsular in March 2014, the new leaders banned the supply of OST opiates methadone and buprenorphine.
Along with over 800 other Crimean clients of OST, Ivan was faced with three choices: leave, detox or risk relapsing into crime and fatal addiction.
The hook: Painkillers
Ivan did not choose to be an addict. It started when he was 15 years of age in 2001. After a serious bike accident left his leg injured, the doctors tanked him up on narcotic-like pain reliever Tramadol.
When he left the hospital, the doctors handed the teenager ten packs of Tramadol, which he shared with his friends.
“After the accident I realized I wanted to live - I drank and had parties and enjoyed life to the full,” he said.
But he wanted to quit Tramadol. Soon he was injecting a home-made stimulant called Vint - a meth-like brew using the ephedrine extracted from cold relief tablets.
“Users advised me to get off Tramadol by getting high on Vint,” he said.
He lost half a year to lack of sleep and food, and memory loss. During this time, he did not wash and slept on the street.
Then Ivan tried shirka - a ‘village heroin’ synthesised from the powdered heads of a Ukraine-grown poppy. He would inject at home, in the countryside, under bridges and in bus shelters.
After he shot an artery with Vint, he felt a tingle, then a spasm and collapsed. It was a stroke. The right side of his body was partially paralyzed, and the pupil of one of his eyes fell to the side.
But he did not stop. Now he took anything to relieve the pain, a cocktail of drugs which gave the effect of feeling as though, as he said: “I was moving on the earth, but also swimming in the sea.”
In 2008 he heard about the availability of OST in the Crimean capital of Simferopol. He entered the local clinic, walked straight into the room of the chief narcologist, and told him:
“I am told you are a very kind man, please help me, or I will die.”
Escaping to society
In 2013, there were 21,100 injecting drug users in the Crimean peninsular from a population of 2.3 million, according to the NGO Alliance for Public Health (Kyiv).
OST was legal in Crimea from 2006. Eight locations in the major towns and cities of the Ukrainian region offered users a chance to withdraw from illegal drugs by replacing them with legal opiates.
There were 806 patients on OST. These centres also gave counselling and medical tests, and were a vital link between an underground culture and public health.
Here users talked, played chess, socialised, celebrated birthdays - even met lovers, married and had kids.
But they also took drugs to suppress the effects of HIV, Hepatitis and Tuberculosis, diseases prevalent among drug users in the ex-Soviet states.
OST gave them a daily routine and connected them to society through a regime which reduced their chances of using hard drugs, sharing needles or contracting HIV.
This option is recommended by the World Health Organisation (WHO) and the United Nations (UN) as an instrument in a toolbox of services to help users quit.
“Comprehensive harm reduction strategies, which include opioid substitution therapy, are essential to prevent and treat HIV, hepatitis and tuberculosis among people who inject drugs everywhere, including in Crimea,” the Secretary General Special Envoy on HIV/AIDS in Eastern Europe and Central Asia, Michel Kazatchkine tell us.
“Harm reduction strategies give people who inject drugs the best chance of leading a healthy and productive life and will help to reverse the rising number of new HIV infections across eastern Europe."
Ivan’s course of buprenorphine took him from under the bridges and out of the bus shelters. Soon he was working as a cargo handler in the nearby port, before finding a job in his chosen profession - a sound technician.
Russia: fast shutdown
But in a near-bloodless coup in March 2014, the Russians seized Crimea. Moscow was reacting to what it perceived as western-backed interference in Ukraine’s democracy. After the fall of the Kremlin-favoured President Victor Yanukovich, Vladimir Putin’s forces and sympathisers annexed Crimea, a region which had been traditionally more pro-Russian and which hosts Russia’s Black Sea fleet.
Russia had banned opiate substitution treatment since 1998 and the new authorities In Crimea gave all the drug providers less than a month to close operations.
In April 2014, the head of Russia’s Federal Drug Control Service, Victor Ivanov, visited Crimea to impose the new policy.
He framed OST as part of a corrupt western attempt to infiltrate Russia’s right to decide its own health policy. In a speech, he denounced the NGOs involved in the organization of OST supply of “representing the interests of western pharmaceutical companies.”
Ivanov trashed the members of civil society members complaining about the OST shutdown, claiming they were “provoking anti-Russian protests among consumers of Methadone and their relatives” because the NGOs feared losing foreign financing.
The drug that had regulated Ivan’s life vanished.
Users were scared that a sudden break in their regime could kill them. They also wanted to show the new leadership that their choice of using OST was not part of a political game to discredit Russian health policy.
In May 2014, Crimean drug activist Igor Kouzmenko filmed drug users imploring Russia to allow them to continue their OST regime.
Ten users braved public exposure to state their case for a humane intervention by Moscow. These included a former ‘liquidator’ who helped clean up radioactive waste from nuclear power station Chernobyl, invalids, pensioners and parents of teenage boys, many of whom were suffering from HIV, TB and Hepatitis.
A couple, sitting in a park with a newborn baby playing in their laps, pleaded: “If we close the program, the happiness we built up over several years will be broken down.”
Each of the users spoke to the camera without anger or despair, stating:
“Please do not let us die.”
Kouzmenko’s video ended with the words: “They do not talk about politics. They do not ask for much. They just want to live.”
But the authorities did not allow the programme to continue.
The users had three options: revert to street drugs, flee to mainland Ukraine to continue therapy or detox in Russia.
Every option but methadone
In Russia’s state-run rehabilitation centres, the medical field sees addiction as a psychiatric issue.
Medicines given to patients include benzodiazepines, barbiturates, neuroleptics and anti-psychotic drugs, such as haloperidol, used in the past to treat schizophrenia.
In the 1970s and 1980s, the USSR employed similar drugs against dissidents as part of a “repressive psychiatry” programme to silence internal opposition and frame critics of the Soviet Union as mentally defective.
“Now they are using the same drugs to treat addicts,” says Anya Sarang, president of the Russia-based NGO, the Andrei Rylkov Foundation.
In Russia, there are also private rehabilitation centres which can use “approved” methods to treat drug users.
These patented techniques include prayer, hitting a patient’s head with a bolt of lightning, electrodes in the ears, shock treatment, telling the patient to imagine entering God’s Temple and swearing to give up drugs, charms to be spoken on Tuesdays and Thursdays for men and Wednesdays and Fridays for women, heating the body to 43 degrees celsius, inducing a coma, and implanting the fetal brain tissue from a guinea pig below the patient’s cranium to reduce the side effects of treatment and abstinence.
Flogging, burying a patient for 15 minutes and spanking therapy are also on offer for addicts. Used as a cure against alcoholism, depression and obesity, a healer smashes a fistful of thick and heavy branches against a patient’s back until the skin bruises.
These methods are all available to addicts, but methadone is banned.
“The rehabilitation and abstinence-based approach is viewed and presented in Russia as an alternative - or in opposition - to substitution treatment,” says Anya Sarang. “But shouldn’t there be many options for [users] to get what they want? To see what would be most helpful for them?”
Russia is experiencing a massive rise in HIV infections. The Russian Federal AIDS Centre estimates that Russia now registers over one million infections. Of greater concern is the centre’s prediction that this could double in two years to two million. From this figure, 60 per cent are injecting drug users.
However the real numbers of HIV carriers could be between one and four million people from a population of 146.5 million. Therefore Russia risks crossing from hosting a ‘concentrated’ to a ‘generalized’ epidemic.
“The lack of substitution treatment is one of the reasons why Russia has not been able to control the HIV epidemic,” says Sarang.
Drug users with HIV are more likely to adhere to a regime of anti-retrovirals if they receive OST treatment for their addiction at the same time - and ideally at the same place.
Also worrying is Tuberculosis, which is on the rise in Russia and is the main cause of death among people with HIV.
Recent research by the Andrei Rylkov Foundation found that, from 13 Russian TB hospitals, the rate of drug dependent patients who dropped out of treatment veered between 70 and 100 per cent.
Over 120,000 are also in prison in Russia due to drug-related crime - a massive increase since 2005. Jails themselves become not only a school for crime, but a hotbed of addiction and disease.
“There are a whole bunch of issues which could be solved if we had this simple intervention [of OST],” says Sarang. “It’s really cheap and cost-effective. If we had that, we could solve all the problems in the medical, law enforcement and criminal fields.”
A way out: suicide and overdose
In the video of Crimean drug users is Anton, in his late 30s, dressed in a hoodie with a wan and pockmarked face and a leg disabled from injecting home-made drugs.
When the Russians took over, Anton went to a rehab clinic in Saint Petersburg. However he did not receive the detox he expected. Methadone creates its own dependency and the doctors were unsure how to tackle the side effects of its abstinence. Anton reverted to using street drugs. In Saint Petersburg, he died of an overdose.
Without methadone users can relapse into taking heroin, and because their body is not conditioned to absorb the drug in the quantity they consumed before going on OST, they overdose - much like an alcoholic, who has been clean for three years, believes he can still neck a litre of vodka in one go.
50 year-old Andrei also pleads for life in the video. A squat man with a moustache and a flat cap, he resembled a typical Soviet public servant.
The centre, says Igor Kouzmenko, offered Andrei a home and a family. Shortly after the film was made, he killed himself.
By December 2014, the Simferopol community of ex-users was scattered across the former Soviet republics.
I caught up with Kouzmenko, who tells me that since the video was made, in Simferopol, which serviced 200 OST clients, 20 have since died.
As well as suicide and overdosing, some died due to complications related to HIV and TB. Because the users were no longer accessing medical services to receive OST, they stopped medication to suppress these viruses.
There are now estimates that up to 100 of Crimea’s 803 OST patients are dead.
Ivan: seizing refugee option
Meanwhile Ivan became involved in protesting for the right to his medication. At a public demonstration in front of the Ministry of Health building in Crimea, he found out about a programme to re-home OST patients in mainland Ukraine.
In July 2014, the Kyiv-based Alliance for Public Health offered OST patients from Crimea and the Russian-backed rebel region of Donbas the chance to stay in a hostel and receive OST medication, in a project supported by the Global Fund. Meals and career advice were available to the users, half of whom had HIV. Many lost their documents because they were running for their lives.
This was a class of “Methadone Refugees”. In summer 2014, Ivan moved to a hostel in Kyiv and worked as a cashier in a supermarket, playing his guitar and singing in his spare time. In the hostel, he put on concerts for audiences of 40.
Ivan gave me a few lines. With a strong tenor voice, he began an a cappella version of the opening lyrics of a Depeche Mode song, which rise high in the first phrase, and then dip low in the second:
“Words like violence,” he sang, “break the silence.”
Music was indispensible from his life “like a hand or an ear”, he said. His ambition was “to have a good job and a good family”.
“Kyiv is the first place in life I can feel complete freedom,” he told me.
One year later I want to find out what has happened to Ivan.
In January 2016, from the 60 “refugees” who made it to mainland Ukraine, seven remain in Kyiv and three in the large southern city of Dnipropetrovsk.
The remainder returned to Crimea, due to their strong links to the territory. It was tough for them to make a new life.
But I discover Ivan is still on OST. He is clean, has a girlfriend and is building and selling amplifiers.
Crimea: Krokodil strikes out
Nearly two years on, Crimea is not a drug-free paradise.
Before the occupation, drug dealers in Crimea were selling homemade village heroin “Cheka” (also known as Shirka) - the most available hard drug in the peninsular.
Also popular was a form of Meth - Vint - which uses the ephedrine extracted from crushed cold and flu tablets.
In Spring 2014, when the Russians took over, dealers suspended their “sale points”, due to uncertainty over the new leadership and a lack of supplies from the mainland. But this was only a pause.
Now Crimea is a closed country, with little access to either the Russian or Ukrainian mainland. Heroin and marijuana, for example, are unavailable, although some legal highs such as synthetic cannabinoid “Spice” have appeared.
Because pharmacies also lack supplies, addicts cannot buy medicine to manufacture into stimulants.
But this has failed to stop problem drug use.
Since mid-2014, dealers switched from selling ‘Cheka’ to krokodil - a form of desomorphine usually extracted from codeine-based pharmacy drugs. This gives users a similar sensation as heroin, but carries huge risks. If poorly made, krokodil can cause giant abcesses in the skin, exposing the flesh to viruses, and paralysing muscles. Users are also making this at home.
“There's nothing but Krokodil here in Crimea,” says Igor Kouzmenko.
Opening picture: Yalta, Crimea, copyright: Petrut Calinescu
Ivan's name has been changed
A feature also published in New Zealand's Matters of Substance magazine