This year marks 20 years since Ukraine first introduced opioid substitution therapy (OST) programme. Over the course of these two decades, experiences were accumulated, with evidence collected to confirm its effectiveness. In addition, mechanisms have been developed to address the challenges and obstacles faced by people who use drugs in Ukraine.
In honour of this milestone, a documentary film by Drug Users News (DUNews) captures the history of the programme, from the first advocacy steps in the 1990s to today’s war with Russia.
“20 Years of Substitution Therapy in Ukraine” is not just the story of a programme that has saved, and continues to save, thousands of lives in Ukraine; it is also a chronicle of the country’s development over the years. Through the lens of substitution therapy, the film shows the path Ukraine has travelled as a former member of the Soviet Union to an independent democratic state, now resisting Russia’s full-scale invasion of its territory.
Punish and isolate vs. treat and support
OST is an extensively researched medical intervention which reduces the risks of illegal opioid use. A strong international evidence-base shows that OST reduces people’s risk of overdose, leads to safer forms of opioid use, and slows the spread of HIV, viral hepatitis, and other diseases. It also improves the quality of life of people who use drugs, meaning they are less likely to resort to desperate measures like crime.
In the former Soviet Union (USSR), OST was first introduced in Lithuania and Latvia (from 1995 to 1996). In Ukraine, however, this only happened much later. By that time, drug use and HIV had considerably spread, becoming a significant problem for the country; intravenous drug use was driving HIV transmission at alarming rates.
At the same time, it became clear that the old Soviet system of drug treatment was not working. The USSR’s drug policy was based on two pillars: punishment and isolation. These methods have been historically proven as ineffective, but they were particularly ineffective at addressing the new reality for those using drugs in a post-Soviet Union Ukraine.
With the need for a new policy, Ukraine turned towards new drug treatment pillars: treat and support. This was an important moment which, among other things, enabled Ukraine to introduce OST. At that moment, instead of repression, Ukraine chose human rights, including the right to health. Instead of the old system of drug treatment, which reflected the totalitarian power of the Soviet Union, Ukrainian activists from the community of people who use drugs and various nongovernmental organisations began to look for ways to implement OST in the country.
This work was not easy; law enforcement agencies and government officials put up strong opposition to many changes. But effective and consistent advocacy yielded positive results. In 2004, the first pilot programmes were opened in the country, a victory for the community and civil society. After that, activists continued to advocate for the expansion of the OST programme and the introduction of additional components, including prescription formulas, hand-delivery of OST, and provision of OST in prisons. Ultimately this led to the state fully funding OST programmes nation-wide from 2017 onwards.
A symbol of democracy and territorial integrity
The introduction of OST in Ukraine took place against the backdrop of a growing desire for democratic reforms that would free the country from Russian influence, corrupt government, and ineffective governance. To this day, OST has remained illegal in Russia, with methadone being a criminalised drug there. Commitment to drug treatment with globally accepted medicines became a key component for Ukraine to demonstrate its distance from Russian influence. This was especially important to highlight after Ukraine’s Dignity Revolution in 2014, which led to a change of power in the country. After that, the OST programme became one of the attributes of Ukraine’s ongoing European integration.
Ukraine’s choice in favour of democratic values led Russia to invade the country and occupy several of its territories over the years: Crimea, parts of Donetsk and Luhansk regions are now under foreign control. Russia promptly shut down OST programmes in the occupied territories, leading to numerous deaths of OST patients who were left without life-saving medications.
In 2022, Russia launched a full-scale invasion of Ukraine. One of the reasons for this war is Russia’s imperial desire to impose its values, including with regard to OST, on neighbouring independent countries. Russia categorically denies the practical use of OST drugs, criminalising access to substances like methadone, and persecuting supporters within its territory and in those countries where it seeks to exert its political influence. Thus, in the newly occupied territories of Ukraine after 2022, it’s expected that Russia will continue its policy of shutting down OST programmes and persecuting people who use drugs. For Ukrainians, fighting the occupier is not only about protecting its territorial and democratic integrity, but also guaranteeing access to its innovative healthcare programmes, like OST and people’s right to treatment and support.
OST programmes on the verge of closure
The protagonists of the documentary are doctors, politicians, drug user activists, staff of non-governmental organisations, and many others. They talk about their work to promote OST and its current situation during Russia’s full-scale invasion of Ukraine. But the film is not just about successes, and it is far from a naïve celebration of the Ukrainian programme. There are great victories, but there are also many challenges that the OST programme is facing due to the ongoing war.
For example, substitution therapy is still a separate program, not integrated into the system of psychiatric care. And this is especially relevant now because of post-traumatic stress disorder (PTSD) experienced by many Ukrainian military personnel. In addition, OST medications are not available at the frontline, with many OST patients now being mobilized into the army. The closure of the programme in Russian-occupied territories remains a serious issue for OST patients there. They have the status of “internally displaced persons” (IDPs) and are often undocumented, as a result of which they cannot become participants of the programme in new locations.
Today, on the Ukrainian frontlines, there is a global confrontation between liberal, evidence-based approaches to drug policy and totalitarian and repressive drug policy, based on stereotypes and stigma, represented by Russia. To date, in the Eastern Europe and Central Asia region, OST therapy remains inaccessible in Uzbekistan and Turkmenistan, as well as Russia. Due to Russian influence, programmes in Kazakhstan and Kyrgyzstan are verging on closure, with other countries likely to follow.
In this sense, the twenty-year history of the OST programme in Ukraine reflects a shared struggle as countries across the EECA region face a monumental choice of social priorities and political values. The battle will wage on.
DUNews expresses its deep gratitude to all those who pioneered the introduction of OST in Ukraine, as well as to all those who have given and continue to give their best to improve the programme today. The film is dedicated to the community of people who use drugs and all those who make their lives better. It was created with funding from the Alliance for Public Health as part of the #SoS 2.0 project. You can support the work of DUNews through Patreon.
