I do it – IDUIT

Author: Olga Belyaeva, Advocacy Manager, EHRA.

 «I was impressed by three unique events recently: seeing the Moon through a telescope, a concert by the rock band Leningrad and our training workshop. Alexander Kudryashev, Minsk. After our meeting was compared to the Moon and the creative and self-sufficient musician Shnur I feel entitled to publish my notes for people who organise meetings for people who use drugs*.

So here’s the task: hold a training workshop based on IDUIT,  which was created by the International Network of People Who Use Drugs with the support of UN agencies. It’s important that we understand and have a clear definition of the role we want to play in the decision-making process and in the implementation of those decisions.  We also need to understand how we can progress from being manipulated by the system to being able to influence decisions, shape state policies and strategies regarding drug policy and programs for people who use psychoactive substances. UN agencies developed guidelines on the proven and scientifically-based interventions that can influence the risks of spreading HIV and Hepatitis C among people who use drugs[1]. The International Network of People Using Drugs (INPUD) developed the IDUIT Practical Guidance that aims to preserve the values of harm reduction and allow community-based implementation of programs during the development, implementation and evaluation of necessary interventions. IDUIT describes how programs for people who use drugs can be carried out from the point of view of meaningful involvement of the communities in decision-making, program implementation and monitoring of their effectiveness. The document answers the following questions: what can we do and what should we do today, given the resources in hand and the circumstances we are in, to stop the spread of HIV and hepatitis C among people who use drugs?

How can we, during the three days of the workshop, share the knowledge and experience of thousands of people who, in some countries, survive despite provocations, killings based on suspicion only and torture, and in others, live safe lives, take part in medical heroin programs and work in cannabis grow shops or drop-in centres?

 

Here are the three components which the living energy of the meetings stems from:

a person from the community who believes it’s extremely important personally for him, for his family and friends to solve the systemic problem that results in repression against people who use drugs. Such a person attracts people with a purpose who are dedicated to changing the society’s attitude to substances and drug policies. There is a community of OST patients in Belarus called “Your Chance” and a movement of students who have the same goals as we do –  decriminalization of all substances and humane drug policy.

conditions. In the countries of our region where the drug policy is repressive and the rights of people who use drugs are very difficult to reinstate, the venue for the meeting should be free from any monitoring or control systems. It shouldn’t be a hotel with security and video cameras that contribute to increased nervousness and risks. Negotiate with a local drop-in-centre; ask people where they feel safe and comfortable in the city. It will help maintain positive dynamics and energy for change within the group. Also, the money that you’ll pay for the venue and food will go to the harm reduction programs and not to some business’ pocket.

 

 

– source of energy to keep moving. For all the living things on earth it’s the sun. For a community movement it’s its values.  An IDUIT coach should have a clear vision of the goal he’s leading the group towards, a coach who doesn’t need words to make us see the future we’re heading for. One’s right to privacy and to deciding whether to use a substance should be protected. Why did doctors in Amsterdam offer an apology to a guy they delivered methadone to while he was out but didn’t wait for him in order to say hello? While in our countries nurses end up behind bars for opening OST sites.  We drew up a layout of our drop-in centre which is cosy and has sustainable financing. It’s the first step towards understanding what we have at the moment and what can be changed. During the discussion, we ascertain and reiterate that it’s impossible to achieve safe and effective risk reduction programs without decriminalisation and science-based regulation of the psychoactive substance market. In Belarus, there is zero tolerance towards substances and people who use drugs. Any amount of substance, starting from 0.00..3 is already too much. “Too much” means 6 to 8 years in prison. The list of illicit substances is drawn up in a way that makes any new synthetic drug formula illegal. When synthetic drugs were legal, – say the participants, – they were used as stimulants: they made things and colours a bit brighter and the high from them made users feel better. Then access and formulas became more complicated. Now we are talking about adolescents of 12 to 14 years of age who consume cocktails the effects or risks of which are impossible to control. And we can’t even talk to them about the risks and ways to reduce them because the system will see it as propaganda of use, especially among minors. Only adults aged over 18 can enrol on harm reduction programs.

We have to be careful all the time about what exactly we’re discussing due to the risk of being jailed for spreading such knowledge. What is “IDUIT”?  It’s a description of approaches to and examples of creating a world in which people who use drugs are free to be themselves. That’s why we study each chapter of “IDUIT” through hands-on training where key values and foundations of the community-based approach are able to manifest themselves: motivational integrity, clear unambiguous goal, realities of the drug scene and ways to preserve the health and mental strength of people who are forced to be invisible for everyone, especially for the system, to survive.

 Chapter One of IDUIT:  empowering the community. We focused on a real-life situation that OST clients in Belarus are faced with – issues with the right to receive medication for self-administration. At the time of the meeting on March 27-29, a new instruction on OST, which included mechanisms for dispensing the drugs, passed the first stage of agreement by experts and civil society. During stage two, when the law enforcement agencies and other executive authorities were to approve the draft instruction, the chapter on dispensing medication for self-administration was removed.   Sergey Kryzhevich and Sergey Gartsev, leaders of the public organisation of OST patients “Your chance” had been responsible for preparing the documents on the part of the community. Together with the participants of the workshop they chose and invited experts to consult with regarding the next steps. This was the key moment for attracting allies and partners – when people are ready to hear about your motives and tasks, understand the goals and see what can be done right now to support the initiative. As a result, we prepared a letter to the Minister of Health requesting a suspension of the approval of the OST instruction and asking to reinstate the chapter on dispensing medication for self-administration. We collected 47 signatures and took them to the Ministry of Health of the Republic of Belarus. We wrote to the UN agencies and to the Global Fund. We organised meetings and telephone consultations with relevant agencies: UNODC and UNAIDS. With the help of the Chairperson of the Country Coordination Mechanism (CCM) – Deputy Health Minister – a working meeting has been arranged involving all those who developed the Instruction, as well as addiction doctors, representatives of UN agencies, OST patients and drug control representatives. The meeting will take place on April 11 and will aim at agreeing the full and final version of an Instruction that will observe the human right for affordable and quality medical care. We have a week to prepare for the meeting thoroughly. Our task before it is to establish the position of all participants and to hold consultations. During the meeting, we take notes and put the outcomes of the discussions in writing immediately after it wraps up. And, of course, we are working on a plan B. The question of dispensing drugs to take home is a fundamental one: people are tired of having to choose between family and addiction treatment, career and addiction treatment, travel and addiction treatment. This is about understanding what Chapter One of the Guidance means in practical terms: it’s about empowering the community through clarifying goals, motives and clear distribution of tasks within a team. It’s also about the meaningful participation of the community in decision-making.

This is Chapter Two of the Guidance: legal reform, human rights, stigma and discrimination. It’s difficult to talk about the rights of people who use drugs in a country where a patient recovering from an overdose in hospital sees the police next to him and then he is taken from the hospital bed straight to court and to prison for three years. People fear that they might attract attention of drug control services if they’re caught looking up overdose treatment for bath salts on the internet. The war on drugs means eight years in prison which in turn means loss of health, money, illness and suffering in the family – things that are completely disproportionate to the effect and quantity of the drug they consumed and subsequently are being punished for.

It was an inspiration to learn there is a movement of students in Belarus who united to achieve humane and reasonable drug policy. We discussed the practical side of decriminalization in Portugal and the Czech Republic. The leaders of OST patient communities had already visited these countries and were confident that we could achieve a similar level of respect for the rights of people who use drugs. We discussed areas where we can support each other especially in the circumstances where we must think about the safety of the experts who help people who use drugs.

 

 

 

Chapter Three of the Guidance – health and support services from the point of view of the community. We discussed the lifestyle of a teenager who suffers from substance abuse. We heard about the work being done with relatives and friends of drug dependent teenagers in order to reduce risks. We prepared draft memos for people who use bath salts drawing on the practical experience of the participants such as people who consume stimulants and doctors. It’s the most pressing issue in Belarus: users of synthetic stimulants (new psychoactive substances) avoid any contact due to repressions, when going online to look up tips on sleep after taking bath salts could attract troublesome attention from authorities. We’ve come up with a plan to spread information. After watching the film “Bevel Up: Drugs, Users & Outreach Nursing”, shot about ten years ago and showing work of Canadian street nurses, the participants realized how far other countries have progressed towards humane and not discriminating attitude towards drug users compared to our countries.

In order to get closer to people who make or influence decisions, a meeting was organised with the representative of the Global Fund Grant Management Group in Belarus. We invited our colleagues from other groups vulnerable to rights violations to this meeting to form partnerships and communicate with community networks. Anya Nazarova, the leader of an initiative to help HIV-positive women (Belarus), attended it. By the time this blog is published, Anya should already become the head of a registered organization.

Chapter Four of IDUIT described community-led harm reduction service delivery approaches. The Global Fund grant for 2019-2021 is set to continue unchanged, but there is an opportunity for pilot projects. Building on their priorities, the workshop participants decided to prepare an application to the Community, Rights and Gender (CRG) Technical Assistance Program to justify the adjustments that should be made to some of the harm reduction programs so that they meet the needs of people who use synthetic substances. We also discussed the creation and funding of community-based and community-led drop-in centres. The money for our services is trapped within the system of repression and war on drugs. We need resources to prepare the rationale and proposals for change. We decided that the application for technical assistance under the Community, Rights and Gender program will help with the rationale.

 

 

 

 

When we arrived at Chapter Five – Program Management, hiring people who use drugs – employment-related questions arose. The meeting participants told us that harm reduction organizations require employees to give a written statement saying that they are aware that it’s forbidden to work while under the influence of drugs or alcohol. The case of Sergey Kryzhevich shows that even the Supreme Court can’t issue a just ruling – he was unable to get his driver’s license back or cancel the fine of 1000 euros even though the evidence suggesting that he had been intoxicated was obtained with violations of some key procedures. In the Republic of Belarus, it’s illegal to be in the workplace in the abovementioned state.  And we, the workshop participants and the employee of the Global Fund grants management team, were asking ourselves why harm reduction programs require their staff to sign such statements when they hire them for the very reason they use substances and therefore are able to help others reduce risks; what can those statements protect the employer from, and what risk do the outreach workers take when they sign them? The issue of the labour rights of people who use drugs has been up for an open discussion. This is the basic principle of the IDUIT Guidelines: to recognise human rights and freedoms, and if that’s not achievable today, to help by all means to achieve the ultimate goal: to exercise the human right to privacy, to respectful, affordable and safe social and medical assistance based on real needs of people who use drugs.

4:20   4th of April 2018

 

The training workshop was organized on the initiative of the UNODC Regional Office for Eastern Europe, prepared and conducted by the Belarusian public organisation “Your Chance” and the Eurasian Harm Reduction Association.

[1] http://www.who.int/hiv/pub/idu/targets_universal_access/en/, the 2012 version. Geneva, WHO, 2013.  Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations–2016 update. Geneva, WHO, 2016.

The EU recommendations on alternatives to punishment for crimes – it won’t lead to a paradigm shift, but it will help advocacy effort

Author: Dasha Matyushina, Drug Policy and Human Rights Advisor, EHRA

On March 8, 2018, the Council of Ministers of the European Union adopted final recommendations on alternatives to punishment for crimes committed by people who use drugs.

The adoption of such a document is an important event, especially given the fact it’s courtesy of one of the main bodies of the European Union. Official documents adopted at the highest level frequently mention alternatives to punishment for drug use and possession – for example, the resolution of the UN General Assembly Special Session on Drugs 2016, the EU Drug Strategy 2013-2020 and the latest EU Action Plan on drugs, adopted just over a year ago.

In fact, the idea is nothing new. Article 36 of the Single United Nations Convention on Narcotic Drugs of 1961, dubbed “Penal Provisions”, defines possible alternatives to punishment:

b) …when abusers of drugs have committed such offences, the Parties may provide, either as an alternative to conviction or punishment or in addition to conviction or punishment, that such abusers shall undergo measures of treatment, education, after-care, rehabilitation and social reintegration in conformity with paragraph 1 of article 38.

The 1988 UN Convention is similar in spirit and style – again we see the terms such as “alternatives to conviction or punishment” and “additional measures”. Law-makers in the USSR and later in the post-Soviet space opted for additional measures such as special prisons for drug addicts and various forms of compulsory treatment…

Is there a significant difference between the international provisions from 60 years ago and the recommendations discussed at the European level today? Why do we think that the international documents adopted over the past few years will somehow help reform drug policies?

First, it’s the official use of the word “alternatives”, which is important. It shows that there’s a consensus that it’s time to try out alternatives to traditional drug policy approaches. Also, the EU documents are gradually moving away from the idea of just “replacing or adding” (which, in fact, allows ample scope for drug prisons), giving clear priority to “replacing” sanctions with non-custodial measures.

Secondly, the EU speaks of alternatives to coercive measures. A fine is a coercive measure which means that a fine for drugs, even a small administrative penalty is not good, it’s a practice that should be replaced with an alternative.

The document adopted by the Council of the European Union in March of this year defines alternatives as follows:

(2) …as education, (suspension of sentence with) treatment, suspension of investigation or prosecution, rehabilitation and recovery, aftercare and social reintegration

Please note that it’s not only the suspension of a sentence but also the suspension of an investigation and prosecution. That means that a decision to send a suspect for treatment or rehabilitation can occur at the time of arrest and before trial.

Another important point is that it’s not just and not so much about sanctions for drug use and possession for personal use, which, according to the document, is not considered “a criminal offense in many countries” (which, as we know, is not entirely true – in the Baltic countries for example possessing microscopic quantities can lead to a fine equal to several monthly salaries). The EU document talks about the whole spectrum of crimes committed by people who use drugs. Most often it’s about thefts committed in order to find money to buy drugs.

The most important thing about the latest EU document is that it recognizes (rather than simply raises the issue for further research) that alternative measures are more effective in reducing repeat offences and social spending, as well as help improve social reintegration.

So, in general, the EU adopted a useful document. It won’t lead to a paradigm shift or a revolution in drug policy; however it will help advocacy effort at the EU and international levels. Our task is to pick quotes from it and target our governments, especially those who still believe that fines and drug prisons are the alternatives to punishment.

Translating realities faced by women who use drugs into human rights language is never an easy task

Dasha Matyushina, Drug Policy and Human Rights Advisor, EHRA

On March 2-3 2018 International Women’s Rights Action Watch Asia Pacific (IWRAW Asia Pacific) organized a workshop – which they call a ‘writeshop’, and I like this name – on developing reporting guidelines for NGOs to report to CEDAW on the violations of rights of women who use drugs.

I decided to make these 34 hours of travel to Kuala Lumpur and back for a 16 hours writeshop because of the study we have organized in Estonia in 2017. It was clear from the very beginning that the amount and harshness of the violations of rights of women who use drugs in Estonia we discovered, created an obligation upon us to produce a shadow report to CEDAW.

What IWRAW Asia Pacific does best is making you feel you are an expert in the Convention on the Elimination of All Forms of Discrimination against Women. They don’t tell you violation of which of the Convention’s articles the case implies, but they give you the text of the Convention and then you tell them whether it’s Article 12 (on health) or Article 16 (on family life).

Translating realities faced by women who use drugs into human rights language is never an easy task but having lawyers in the rooms really helps.

Deprivation of child custody solely because of drug use, which we found to be so prevalent in Estonia, violates Article 16. Non-provision of quality drug treatment services for women with children is the violation of Article 12. Arbitrary arrest and detention of women whom police know as drug users, which we surprised to discover in an EU state, violates Article 2. There is more of cause, but I will always remember CEDAW articles 2, 12 and 16.

EHRA’s research on human rights violations in the EECA will continue, and so our partnership with IWRAW Asia Pacific will. Our next field research is going to happen in St. Petersburg and Leningrad oblast in Russia – a border region with Estonia’s city Narva. We will compare the situation in Russia and Estonia through the lens of CEDAW articles – and we will probably to find more similarities between the policies of these two states that the human rights movement would expect.

Harm Reduction Beyond Numbers

Author: Péter Sárosi, Drugreporter

How cultural attitudes, the political environment, and donor expectations shape harm reduction – and how they can divert it from its original mission as a movement.

We have been producing movies about drug policies since 2007. Through all these years, we have been traveling a lot across the world, visiting harm reduction sites and interviewing hundreds of harm reduction activists, professionals, and decision makers in various countries.

It is easy to make premature judgments about harm reduction in a country. I always have my own preconception about it before actually traveling there, based on articles and reports I have read. Most of the time, I have to admit that the reality is much more complex than my expectations. My experience tells me that sometimes countries labelled as retrograde in terms of drug policy and harm reduction can amaze you with vivid, vibrant local harm reduction scenes. And countries praised for their progressive drug policies can equally disappoint you with their rigid, medicalised systems.

Sometimes you learn the most cutting edge lessons about harm reduction and human rights among the people living in disadvantaged countries. A mistake often made is that the experience of these people is underestimated, and only success stories are highlighted and celebrated by reports from international organisations. Exchanging experiences and knowledge among decision makers and harm reduction professionals working in similar, difficult environments is often as useful as presenting best practices from Western countries. Lack of measurable success in changing policies is not necessarily a sign of the failure of advocacy efforts.

Harm reduction is of the people, for the people, and by the people. Assessing scientific data about trends of infections or access to services is necessary when measuring the social impact of harm reduction as a set of interventions. But statistical data in itself is far from sufficient to have a real insight into how harm reduction works as a movement, how is it embedded into the local political and cultural context, and how it affects the lives of individuals and communities.

We can identify some main factors shaping and framing harm reduction. These structural factors are actually not so different from those shaping the individual drug experience. Since the 1960s it has been a commonly accepted wisdom that the drug experience depends on three factors: set (the mindset of the drug user), setting (the physical and social environment), and dose (of the substance used). Similarly, three factors can largely determine harm reduction in a country:

1) Cultural environment – Social attitudes to drug use, historical development of the drug treatment system, education and attitudes of public health and social professionals, the influence of abstinence-culture, and the role of religion and church.

2) Political environment – State of democracy, freedom of association & power of civil society, type of government, the state of development of the welfare state, drug laws, law enforcement practices, public health regulations, and the external influence of neighbouring countries.

3) Funding environment – Who is funding harm reduction, what is the framework of the funding, what are the donors’ expectations about supported activities, how the money is distributed.

Western European cities are the best propagated examples of how we can reverse drug related death and disease by investing in harm reduction. Services are well funded by the government, well connected, and coordinated to municipal health, social and criminal justice systems. The political and cultural environment is tolerant or supportive. However, city leaders often embraced harm reduction from a cosmetic point of view: to get rid of street nuisance and bad press coverage. In developed countries high-tech, well-funded services often work without real mobilisation and involvement from drug user communities. The best services are sometimes not only the well funded services – but those operated by NGOs investing a lot of time and energy into advocacy, community mobilising, and peer involvement.

Harm reduction has been mainstreamed in much of Western Europe. It is business as usual, operated by technocrats or public health officials paid by the government, working according to official standards. If you attend a harm reduction conference in Europe you will meet social workers, public health pundits, and law enforcement officials discussing research findings, grant systems, and professional protocols. The contrast is stark if you attend a harm reduction conference in the US, where harm reduction is still an underground movement challenging the status quo of the mainstream abstinence culture and tough-on-drugs policies. Funding is unstable, whilst federal funding for needle exchange was banned until recently. You will see way more rebels and punks at these events who discuss social justice and structural racism. While harm reduction is – sometimes grudgingly – accepted by even social conservatives in Western Europe, it is more like a Leftish guerrilla movement in the US, driven by drug user activists and radical social workers. The opiate overdose epidemic has been recently helping harm reduction become part of the mainstream – at a terrible cost in human lives and suffering.

In most Eastern European and Asian countries you often see broken down hospitals, burnt out and underpaid health professionals, and understaffed and under-equipped services. HIV infection and overdose death rates can be rampant. Criminal laws are repressive. Drug users are often coerced into so-called treatment programs. In this hostile environment, harm reduction could only lay down roots with the help of international donors, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. Its positive impact is tremendous in reducing new infections and scaling up HIV treatment and prevention among the so-called key populations. Without the support of the Global Fund, these communities would have no voice and no future.

However, harm reduction dependent mostly on international donors is like a plant nurtured indoors by artificial light, with no deep roots in the cultural and political soil of the hosting society. Whilst the funding environment is favourable it may flourish. But as soon as it is deprived from international support and is exposed to the harsh outdoor environment, its fragility will be revealed. This happened when the Global Fund changed its funding policy after the financial crisis and many countries lost their eligibility. This resulted in the sudden collapse of many community-based harm reduction services and the further marginalisation of injecting drug users. Many people died as a consequence. Service providers tend to follow the flow of the money. Many abandoned harm reduction services and chose a different survival strategy. It soon appeared that by only focusing on funding services without investment into public education and community advocacy, international donors could not make harm reduction sustainable.

Donors do not only fund and shape harm reduction – they can also distort it.

For example, they often put harm reduction in the framework of HIV prevention and thus into the realm of public health interventions. National donors often subordinate harm reduction to treatment and prevention. These reductionist interpretations of harm reduction as a set of public health interventions are devoid of many other important dimensions of psychoactive substance use. For example, the social dimensions of poverty, exclusion, institutional racism and segregation, homelessness, and unemployment. Or the legal-political dimension of repressive criminal laws that are pushing substances and people who use them underground. To address these systemic factors harm reduction must go beyond public health interventions and mobilise marginalised communities against repressive and exclusive government policies and laws. Criminal justice reform must be an essential part of harm reduction – but it has not been on the agenda of many harm reduction organisations.

Second, putting harm reduction into the context of HIV prevention reduces its focus to only injecting drug use. While injecting drug users are far more marginalised than any other groups of drug users, harm reduction as a philosophy and practice must go beyond injecting use and transform the way we perceive drug use in general. It should include pragmatic and compassionate programs to reduce the harm of recreational drug use as well, for example in a party setting – even if it has nothing to do with HIV prevention directly. The vast majority of drug users are non-injecting recreational drug users, reaching them is not only important to avoid accidents, but can do a lot to promote the acceptance of harm reduction as a guiding principle among the general population. In countries where harm reduction is dependent on Global Fund, programs supporting party-going young people are underfunded and scarce. When streets were swamped with new psychoactive drugs, and new patterns of drug use and distribution started to trend among young people, programs designed to serve opiate injectors could not cope with these problems.

Third, big donors shape their grantees in their own image. It is very easy for NGOs competing for limited resources to lose sight of their mission and to follow the expectations of the donors in order to secure funding. But donor expectations about ideas, supported activities, regions and groups do not shape how NGOs and community groups work alone. To apply for grants, to manage grants, and to report to the donors requires huge investment in time and human resources. The bureaucratic processes required by donors change the perception of time, staff, services – and in the end, the mission of the organisation. Many grantees realise that for the donor it is not the real social impact that matters but organisational stability in managing and reporting grants. Community activists often transform into technocrats who lose the connection to the communities they serve. When activists speak a language full of jargon and acronyms only the selected few understand, their arguments do not appeal to the general public or to hostile neighbourhoods.

National and international donors must learn the lesson and invest more into community organising, public education, and advocacy to change social attitudes and policies about people who use drugs. Without transforming the set and setting, that is, the cultural and the political environment, harm reduction is vulnerable and cannot adapt to new challenges. Where harm reduction is not well embedded into and accepted by society, and not well connected to the community, sudden changes in the political environment can lead to collapsing services even in countries where national funding for services is available, as exemplified by my own country, Hungary.

Rigid rules by international donors about governance and co-funding favour big organisations based in wealthy countries over community activists living and working in repressive environments. These rigid rules do not guarantee the social impact of grants. Investment into people rather than just organisations, services, and projects can do. Sometimes the best ideas and initiatives come from grassroots activists and community groups without well established governance structures. Instead of requiring grantees to transform into grant processing companies, obsessed with Western-type management methods completely alien from community activists working on the ground, new flexible rules and modes of funding should be developed. Forging synergies among social movements is also important – they cannot win in isolation. They can learn a lot from each other about innovative advocacy methods to mainstream their messages. Only together they can fight austerity measures, rising right-wing populism, and the new authoritarian crackdown on civil society. In the end, the success of harm reduction as a movement depends on the larger context of social justice movements, the state of democracy, and the existence of a strong civil society.

Source: Drugreporter

Pilot OST Programs in Kazakhstan – How to Avoid Being Thrown Overboard

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.

LITHUANIA: WHERE ONE SHARED JOINT MAY COST YOU LIBERTY

Author: Eliza Kurcevic

„After the New Year, for the smallest amount of marijuana – criminal liability and immense fines, „In one of Vilnius bars, police made a raid: Some of the bar visitors were scared, some were laughing“, „A young man was sentenced for the distribution of drugs, committed a suicide in the Lukiškės Remand Prison“, „Penalties in Lithuania: for one shared joint – imprisonment from 2 up to 8 years“ – those are just a few titles of the headlines in the news portals, during this year (2017). This is definitely a year of failures and regress in the terms of drug policy, where policy makers started to treat people in Lithuania, as drugs itself: isolating, controlling and containing. And while some of the European Union countries already have a great experience in the process of the drug liberalization by creating tolerant, human rights based approach of the psychoactive substances possession for the personal use (such as Czech Republic, Portugal, The Netherlands), opening drug consumption rooms (The Netherlands, Germany, Denmark, Spain, France, Luxembourg) or prescribing heroin-assisted treatment (Denmark, Germany, UK, Spain, The Netherlands), Lithuania is coming back to the rotten roots of old laws, where punitive and prohibitionist policies were worshiped. And here I speak about Soviet Union times, when for the possession of drugs you could get up to 15 years imprisonment. So what‘s happened in Lithuania (or should I say WITH Lithuania?)?

A GLANCE INTO THE DRUG POLICY SITUATION IN LITHUANIA, IN 2017

I can’t call the beginning of 2017 as a great start of the New Year in the context of the drug policy. Before 1st January, 2017 provision on the possession of the small amounts of the psychoactive substances was considered as a matter of the administrative liability by the Administrative Offences Code. But starting from the 1st of January, 2017 possession of the psychoactive substances (any amount of it) is regulated by the Criminal Code and considered as a crime or misdemeanour[1]. Unfortunately, I can’t get in the heads of our policy makers and rational explain what kind of blackout they had so they decided to move these provisions from administrative to criminal liability. But seems they got confused about separation of criminal and administrative liabilities and just moved all that kind of provisions to the Criminal Code. And this is the best example of the punitive mentality: if you don’t know how to treat a person – give him/her the worst penalty. So, Lithuanian policy makers did it and the bedlam started in the heads of the Lithuanian citizens.

When the first cases, related to the possession and distribution of the small amounts of the psychoactive substances in 2017 appeared in the courts, judges didn’t feel like they want to punish young Lithuanian citizens with the custodial sentence for a term of up to two years (in case of the possession) and custodial sentence for a term of two up to eight years (in case of distribution). Special attention during investigations was taken in the cases where famous Lithuanian person’s children were caught or children from “good families”. So what courts did in the most of the cases – they gave a fines or based on the principle of justice gave a suspended sentence (when imposition of the penalty provided for in the sanction of an article is evidently in contravention to the principle of justice, judge can impose a commuted penalty subject to a reasoned decision). But these decisions actually didn’t help young persons, as they got criminal convictions for several years. Just to imagine, how messed up we are: approx. 800 pre-trial investigations on the possession of the psychoactive substances have already started this year. 537 suspended sentences were imposed in pre-trial investigations. But let’s move on, as there were more consequences of these harsh laws.

One May evening, popular bar in Vilnius „Peronas“ was „visited“ by the police. It lasted about 15 minutes. All this time police were distracted by not knowing what to do, were running around the bar. Please, check video (really worth to see this ridiculous raid). „Some of the bar visitors were scared, some were laughing“, says the owner of the bar. After raid there was no more information from the police, no warnings. So what was the point of this raid? What the police wanted to show by organizing it? Instead of concentrating on the catching up large-scale dealers, police started to organize bars visitors frightening actions. But…that’s only one example from dozens, which happened this year.

Situation started to get worse in autumn. One morning I woke up with a new “A young man sentenced for the distribution of drugs, committed a suicide in the Lukiškės Remand Prison“. I couldn‘t believe that this is real, that this is happening in the XXI century in Lithuania. He was only 21-year-old. After the decision (custodial sentence) was made, the young man was found dead in the camera. He made a suicide. NOT drugs killed him, but draconic and disproportionate laws, which take off any hope! The fear of cruel, brutal, inhuman conditions in the prison made a young person to make a suicide.

And for the end I left the newest updates, which made a lot of families, lawyers, judges, members of the society to rethink towards where we are moving on. Starting from the 6th October 2017 Criminal Code was „patched“/amended. The policy makers decided that it‘s time to fight with corruption. How it is related with the possession of the psychoactive substances? These amendments prohibited to suspend a sentences for a serious crime. But as judge A. Cininas commented „The motives were beautiful: the fight against corruption, fraud. But serious crimes also include activities such as sharing joints of cannabis between the teenagers”. So basically, if one day I will be smoking joint and my friend will ask to share it with him/her, and we will be caught by police, this will be interpreted as a possession of a psychoactive substance with the purpose to distribute it. And by amended laws judge will be obligated to give me a custodial sentence for a term of two up to eight years (no suspension, as this crime is included into the „serious crimes“ category). Which as you already understood, means, that I will go to the prison from two to eight years. Does it make sense? Well, in the country where drugs are criminalized and punitive mentality can‘t leave it roots – probably it does.

Until now, Lithuania has done little to reduce crime or to take attention on the large-scale dealers. Starting with the new law (amendment of the Criminal Code from 6th October, 2017) we will have prisons filled in with young, low-level, non-violent individuals.

So maybe instead of putting low-level „criminals“ into the jail, let‘s take a look to the progressive approaches, let‘s check how other European Union countries deal with the issue. A variety researches showed that treatment-based, education and simply human rights based approaches are the most effective and giving the results.

Next month I will update you with the situation in Lithuania and using the Portuguese model of decriminalization, will show what changes we can make in our system.

TO BE CONTINUED…

[1] Article 259. Unlawful Possession of Narcotic or Psychotropic Substances for the Purpose Other than Distribution 1. A person who unlawfully produces, processes, acquires, stores, transports or forwards narcotic or psychotropic substances for the purpose other than selling or otherwise distributing them shall be punished by a fine or by arrest or by a custodial sentence for a term of up to two years. 2. A person who <…> a small quantity of narcotic or psychotropic substances for the purpose other than selling or otherwise distributing them shall be considered to have committed a misdemeanour and shall be punished by community service or by restriction of liberty or by a fine or by arrest.
Article 260. Unlawful Possession of Narcotic or Psychotropic Substances for the Purpose of Distribution Thereof or Unlawful Possession of a Large Quantity of Narcotic or Psychotropic Substances 1. A person who unlawfully produces, processes, acquires, stores, transports or forwards narcotic or psychotropic substances for the purpose of selling or otherwise distributing them or sells or otherwise distributes narcotic or psychotropic substances shall be punished by a custodial sentence for a term of two up to eight years. 2. A person who <…> a large quantity of narcotic or psychotropic substances for the purpose of selling or otherwise distributing them or sells or otherwise distributes a large quantity of narcotic or psychotropic substances shall be punished by a custodial sentence for a term of eight up to ten years. 3. A person who <…> a very large quantity of narcotic or psychotropic substances shall be punished by a custodial sentence for a term of ten up to fifteen years.