As an addiction medicine specialist in Armenia, I often meet patients that, lowering their voices, tell me: “Doctor, please don’t let anyone know I am on methadone.”
Addiction treatment in many post-Soviet healthcare systems has historically been associated with shame, stigma, fear of being monitored and distrust toward health institutions. These forms of stigma are not only social, but also embedded in legal frameworks, healthcare structures and everyday interactions, shaping how individuals experience and access treatment.
This shame persists despite the fact that Opioid Substitution Therapy (OST, also referred to as Opioid Agonist Therapy) is widely recognised as one of the most effective evidence-based treatments for opioid dependence and is recommended as a core component of modern public health responses to opioid dependence.
For decades, Armenians living with opioid dependence have consistently been the second largest group in drug treatment settings, second only to cannabis. Heroin is the drug of choice, with consumers mostly injecting it. In recent years, changing drug markets impacting heroin’s supply in Eastern Europe, as well as the inherent risks to drug injecting, have made accessible and effective treatment more important than ever.
OST was introduced in 2009 at the National Centre for Addiction Treatment in Armenia (under the Ministry of Health). When it started, only 32 patients received methadone doses; today, around 1,200 patients are enrolled in OST treatment programmes across the country and even within Armenian prisons, with just over half (625 patients) at the National Centre.
Uptake still lagging
Despite this expansion, increased access has not translated into full uptake among those who could benefit from OST. A significant treatment gap likely remains between those in need of treatment and those who actually receive it. This gap is not only structural, but deeply rooted in stigma, legal barriers, and long-standing social perceptions of addiction. In many post-Soviet contexts, opioid dependence continues to be viewed as a moral failure rather than a medical condition, which directly affects how treatment is perceived and accessed.
In Armenia, OST access is also regionally limited. While Armenia has ten regions, substitution therapy is currently available primarily in the capital, Yerevan, and in only three others – Lori, Shirak (Gyumri), and Syunik. For those living elsewhere, treatment access usually means long travels and greater expenses. Treatment choice is also restricted. OST in Armenia mostly means methadone; there’s little access to alternatives like buprenorphine, particularly in the public settings. This limits the ability to tailor treatment to individual needs and preferences, discouraging some from entering care.
Legal and administrative barriers further complicate access. Many people avoid substitution therapy due to fear of being formally registered as a person with substance dependence. As in many other post-Soviet nations, once you’re in treatment, the label of “drug addict” will follow someone for years, recorded clearly in official documents for law enforcement and other public officials to see.
This registration can have long-term consequences: people can lose their driving licenses or be limited from certain types of employment, such as public service positions, security-related jobs, transport and driving roles, and other positions involving a high level of responsibility. Even if someone’s not using drugs anymore, they may remain under observation for up to five years and be subjected to regular drug testing during that period to be removed from the “addict” registry.
Sadly, little has been done to change public perceptions around drug treatment, particularly of opioids. OST is often perceived by the general public – including family members – and in clinical settings as replacing one drug with another, rather than as a legitimate form of treatment. True “recovery” is only seen as achieving abstinence, with stable life on a medicine still seen as a failure.
This narrative is incredibly damaging to evidence-based care. In my clinical practice, including my experience working in the OST department between 2019 to 2026, it is not uncommon for family members of those in treatment to oppose substitution therapy or question my or my colleague’s decisions, even urging clinicians to discontinue treatment. There have also been cases in clinical practice, including my own experience, where patients said that family members threw away their take-home methadone doses, throwing their treatment into disarray and potentially causing acute opioid withdrawal.
As a result, many in Armenia delay treatment or avoid it entirely: it’s understandable that some may feel that navigating opioid drug use by themselves may be easier than going through a treatment system that exposes them to long-term legal and social consequences.
Criminalisation continues to play a significant role in shaping these dynamics. When problematic drug use is framed primarily as a criminal issue rather than as a health condition, it reinforces punitive responses and perpetuates stigma. In Armenia, drug criminalisation remains unchallenged: under current government policy, drug use and possession are addressed primarily through legal and punitive measures, and there is no legal framework for the decriminalisation or legalisation of drug use.
In practice, gaps in coordination between health and law enforcement systems can create additional barriers. Patients receiving methadone treatment may be temporarily detained by police on suspicion of illegal possession of methadone until their treatment status is verified. In some cases, this detention can last up to 72 hours. Verification may be completed more quickly on working days, but delays are more likely during weekends on non-working hours, when official confirmation is harder to obtain. Even short disruptions in treatment can negatively affect continuity of care and further discourage engagement.
The need for reform
While comprehensive national data is limited, clinical experience suggests that engagement in substitution therapy is associated with improved social outcomes, including reduced involvement in criminal activity and better reintegration into daily life.
So can we, in Armenia and beyond, make sure that patients feel confident that treatment will be beneficial to them?
A key turning point came in 2020, during the COVID-19 pandemic, when Armenia introduced more flexible approaches to opioid substitution therapy (OST). Stable patients – defined as those who are clinically stable on treatment, adhere to prescribed medication, do not exhibit high-risk behaviours, and can safely manage take-home medication – were able to attend clinics once a week, taking one supervised dose at the clinic while receiving take-home doses for the following six days.
This patient-centred adjustment helped improve treatment retention by reducing the burden of daily clinic visits and enabling individuals to maintain employment and social stability. These practices were later reinforced through regulatory changes, with amendments introduced by the Ministry of Health in 2022 allowing take-home medication for multiple days, in some cases covering up to 10 days treatment.
Although Armenia has made important progress toward a more health-oriented drug policy, stigma and criminalisation continue to shape public attitudes and institutional practices. Building on recent reforms requires long-term efforts to improve treatment quality and access while strengthening trust in the healthcare system. Dependence must be recognised as a health condition rather than a moral or legal failing, requiring coordinated responses across healthcare, social services, education, law enforcement, and media.
Reducing stigma should be a central priority. This includes promoting person-centred approaches, eliminating harmful language, and removing legal and administrative barriers that discourage people from seeking treatment due to fear of social or legal consequences. Expanding services beyond major cities, ensuring continuity of care, and supporting early prevention efforts are also key to improving outcomes.
These challenges reflect broader patterns across post-Soviet systems, where drug use has historically been framed as deviant behaviour rather than a medical issue. Yet the effectiveness of opioid substitution therapy depends not only on pharmacology but also on trust: when people trust healthcare providers, they are more likely to seek support, remain in treatment, and rebuild their lives.
Armenia’s experience shows that expanding access to OST is necessary but insufficient without tackling stigma, reforming legal frameworks, and prioritising a comprehensive, health-based response.
