Sex, rights, gender: hastening the sunrise

EHRA Senior Program Officer Maria Plotko spoke with chairwoman of the board of the Club ” Svitanok ” Svetlana Moroz about their study on “Access of women who use drugs to sexual and reproductive health, HIV and harm reduction services in Donetsk and Lugansk oblast”, advocacy for the rights of women who use drugs, and the situation with gender-sensitive services in Ukraine.

Could you please tell us about your research? How did it appear and what are the results?

It all started in 2018, when began planning our first large project aimed specifically at sexual and reproductive health of women who use drugs in Donetsk and Lugansk oblast. This is a zone of military conflict in Ukraine. The project was funded by “Doctors of the World” (Médecins du monde) from their office in Paris. There were three main objectives. First to improve access to services, second to assess the needs, and third to build a network of friendly medical institutions and doctors.

As part of the second objective on needs assessment, we decided to conduct a community-led research. As a result, we interviewed 150 women who use drugs. 100 from Donetsk oblast, 50 from Luhansk. This study helped us better understand the socio-economic , and other barriers including internal ones related to armed conflict, which prevents women from accessing the sexual and reproductive health and other services.

We conducted two roundtables in Severodonetsk in Kramatorsk, where we invited as many stakeholders as it was possible – government officials, representatives of law enforcement and social services. Of course, representatives of the community of people who use drugs, women who use drugs. At the beginning of last year on the basis of the study report we prepared questions for the List of issues for  Ukraine  in the context of the implementation to the UN Convention on the Elimination of all forms of Discriminations against Women (CEDAW) and spoke at the meeting of   the Committee in Geneva.

How did the stakeholders in Ukraine react to the results of your research?

Ambivalently. In Severodonetsk I remember the woman who is responsible for the supervision over the work of law enforcement bodies, when hearing some of the stories about police violence, asked to send her the link to the full text of the report to check it out. We, in turn, on this round table learned that during the reallocation of drug addiction center from Luhansk to Severodonetsk,  only the male branch was left and female – not. This means that now drug dependence treatment in hospital is accessible only for men. Local community groups try to push this agenda but, unfortunately, they did not have much success.

 

In Kramatorsk, a representative of the regional health department was surprised to hear that women did not seek ART. “How is it possible that women did not seek ART? It is available!”. So we had to discuss that the availability of ART in the AIDS  Center or in the center for infectious diseases does not always mean that women who use drugs will go there. It might be related to other, so-called social determinants, like stigma, discrimination, poverty, lack of information. The results of our research were also useful to the initiative group of women who use drugs from Slavyansk, when they joined regional coordination committee on AIDS and Tuberculosis.

Do you think the officials heard you? Has this research helped to bring any changes?

Actually, speaking about the work of these regional coordination councils, we are sometimes just glad that they meet. In general, they are quite sympathetic. But on the other hand we would like to see some political will, concrete actions, but this is more complicated.

In the pre-war times, we have had many effective solutions and this partnership gave results. In the current situation, HIV – positive people, key communities, unfortunately, have not yet become a priority. We have to prove over and over that you should not disregard these groups. People still have these stereotypes you have treatment, substitution therapy therapy, ART – what more do you want?

Therefore, issues related to human rights, stigma, discrimination, and especially gender inequality, are very difficult to convey, to convince officials that these issues matter and must be dealt with. Our study is one of the few resources and arguments.

We also shot a film in collaboration with Drug Users News , it is called “Waiting for the Sunrise. Women of Donbass” (Svitanok means sunrise in Russian). In this film there is a part about the woman who was tortured in the Luhansk People’s Republic in 2014 for being a patient of opioid substitution therapy. At Svitanok has its own history with Natasha Zelenina , who was sentenced to 11 years for drug trafficking in the so-called Donetsk People’s Republic. We are still fighting for her freedom,  the European Court  of Human Rights already issued interim ruling, and Natasha was  included in the prisoners’ exchange list, but continues to be held illegally in the occupied territories. When we talk about this at the meetings of Ukrainian coalition on CEDAW, to other women, and feminist organizations, it helps to make them understand why women who use drugs should not be excluded from the feminist agenda.

Could you speak more about the coalition on the report to CEDAW. Is it the first time you participate in it?

As Club “Svitanok” yes. Previously, we engaged with it through national organizations, participated in various meetings. I  like this coalition because it is really very diverse. It includes both women with multiple discrimination, and traditional for CEDAW groups like Roma and rural women. We are fighting for our marginalized women to also become a tradition. This year I was invited to facilitate the session on women living with HIV, and women who use drugs.

Now the finalization of the coalition report is underway, although it is not yet clear when the Committee will consider Ukraine, since Ukraine itself has not submitted the ninth periodic report.

For how long has this coalition exists and who is coordinating it? Does it work only within the framework of CEDAW or does it also deal with other issues?

It definitely isn’t its first year, back in 2014 “Positive women” was asked to delegate representative to share expertise on women living with HIV. And in 2017, we were invited to participate in the development of national plan for monitoring of the implementation of the Convention and the recommendations of the Committee. This is also an important that we not only write reports, but also participate in monitoring processes at the country level. The work of the coalition is coordinated by Kyiv Institute of Gender Studies, they have established good cooperation with the Ministry of Social Affairs, embassies and foundations that promote women’s equality. 

In November 2020, 140 people gathered at the webinar to discuss report to CEDAW. This is the first time I have witnessed such involvement at the national level. There were womens’ organizations from all over Ukraine, plus officials as high as deputy ministers.

Is it possible to build new partnerships through this coalition? Promote issues such as access for women who use drugs and/or living with HIV to shelters for women survivors of violence?

Of course it is possible. I think in some ways we have contributed to the fact that the 2018, Prime Minister Volodimir Groysman signed the new standard position on shelters, which removed  infectious diseases as a barrier. Which means that now women living with HIV have unrestricted access. Although, we still have to work on removing ” drugs or alcohol intoxication”.

One of the coalition’s members is Government Commissioner for Gender Equality Kateryna Levchenko. So there are people responsible for shaping public policy in the context of gender equality and can be our allies.

How would you assess the overall situation with gender-sensitive services in the context of HIV in Ukraine?

Promotion and implementation of gender sensitivity in HIV programs is very ad hoc, not structured, not organized, mostly through the initiative of individual organizations. And I believe that we still have quite limited expertise in this. Although it declared everywhere, but in fact the number of real gender transformative services and interventions is very limited. Usually everything comes down to  “we fund women’s organizations.” And the idea that gender policies should be cross-cutting in all organizations that work in HIV is not promoted in any way, unfortunately.

There are local governments that try to ban the use of the word “gender” in normative documents altogether, and do not accept gender programs. On top of that the prohibition of equality marches in support of the LGBT community and inter-factional groups in parliament that advocate “traditional values”. Soon we will have women’s march. We’ll see. This is usually a very important event for us.

March 8?

Yes. In Kiev we are usually guarded by lots of police, because often there are attacks, Zelyonka (triarylmethane antiseptic dye) or gas attacks. Sometimes it seems that there are more police officers than participants. March organizing committee is planning security system, communication, organize columns and ambulances, so it would always be nearby.

Such a harsh reaction to the fact that women are defending their rights?

As if that wasn’t enough, there are anti-feminists and other women who come and try to join us in a column and shout their own slogans “Death to feminism” and all that. And in small towns it is even worse. If the police do not work adequately, then the participants of the marches suffer greatly.

What is the attitude towards women living with HIV and women who use drugs in the march organizing committee? 

It’s ok with women living with HIV as long as they don’t touch the topic of sex workers and motherhood for women who use drugs.

 Last year we spoke in support of sex work and came across a lot of criticism. The fact that we oppose Article 164 of the Family Code, which says that drug addiction, alcoholism can be grounds for deprivation of parental rights, is also not supported.

Do you think it is likely that 164 article abolished will be abolished any time soon? Are there any advocacy activities on this issue?

Organisation VONA does a lot to promote this. They’ve created a movie with Drug Users News  “Targets” , and also wrote to the office The Ukrainian Parliament Commissioner for Human Rights. She replied that she “saw no signs of discrimination”.

But, nevertheless, we had a big victory last year, on February 25th. On that day, the ECHR ruled  in favor of drug dependent women from Russia who was deprived of her parental rights. On the same day, we won an appeal in court in Dnipro regarding the parental right of HIV positive drug dependent woman. Our activist Luda Kolomoets from “Positive women” worked on this case together with other lawyers.

How accessible is legal aid to women in such situations?

Now this area is actively developing, even the Global Fund supports it. It is already recognized as a priority at the level of national policy, for example, in a strategy for an integrated response to human rights barriers which includes ccess to justice for women from key populations, including women who use drugs.

 

In 2020, as part of the Eurasian Regional Consortium project “Thinking outside the box: overcoming challenges in community advocacy for sustainable and high-quality HIV services” with the support of the Robert Carr Fund for civil society networks (RCF), EHRA issued 3 sub-grants to promote community-led research. Club “Svitanok”.  

Club ” Svitanok ” is the first organization in Donetsk region created by HIV-positive people who use drugs. Club “Svitanok” provides assistance to HIV-positive and drug dependent people. Since 2012, Svitanok  focuses on working with marginalized women.

https://club-svitanok.org.ua

Help impossible to ignore

Marija Sketre, EHRA Senior Program Officer and Ganna Dovbakh, EHRA Executive Director

Our dreams

On International Women’s Day, we asked partners to share their ideas of support that should be offered to a woman using drugs experiencing violence. We share their dreams of safety, support, solidarity and protection of rights:

“Addressing violence towards women using drugs should be low threshold, integrative shelter, meeting women where they are – client-centered and client-oriented – offering variety of services to answer multiple client needs from health care response to psychosocial and legal support.”  Irena Molnar, ReGeneration, Serbia

“Shelters should provide safe space for ALL women, regardless of their status. Women using drugs are particularly vulnerable to violence, thus shelters should be non-discriminatory places, where acceptance prevails, and health services are provided. It also relates to achieving the Istanbul Convention goals, which we all strive for!” Tatjana Stoimenovska, HOPS (Healthy Options Project Skopje), North Macedonia

“I want shelters in every city to be a safe space filled with care and warmth, with friendly atmosphere and sisterhood approach! In this shelter a woman can receive all the necessary services and live from one day to 6 months. Solving her basic needs, a woman has the opportunity to take vocational courses, find a job, take her children from the orphanage, gain confidence and stability in the future!” Elena Bilokon, My home, Kazakhstan

We are worried

Unfortunately, the reality is very disappointing, and we are very far from such dream. According to the World Health Organization (WHO), every third woman experiences intimate partner violence. Women using drugs, according to some studies, experience gender-based violence three to five times more often than women in the general population.

The problems of women using drugs experiencing violence in our region primarily include:

  • stigmatized attitudes of the family, social services and the whole society towards the problem of female dependence on drugs, including self-stigma;
  • difficulties with personal safety: a woman’s vulnerability to the police in connection with drug use, difficulties with accommodation in existing shelters, the risk of minor children removal;
  • difficulties in accessing psychosocial care due to discrimination on the part of social services providers, health centers and other organizations that could and should provide assistance.

Often a harm reduction organization, social worker or outreach worker is the only support available to a woman. Even so, the support in harm reduction programs and opioid substitution therapy centers for women experiencing gender-based violence, police and intimate partner violence is limited. Not all organizations have street lawyers, psychologists, psychiatrists, programs do not always guarantee personal safety and confidentiality of data, there are no safe rooms where only women can come or there is no time allocated for women only, there are no childcare services, there are no services for women, sex workers, homeless or transgender women who have experienced violence.

Emergencies such as natural disasters, situations of armed conflict, economic crises and pandemic situations – as the recent COVID-19 pandemic – significantly increase the likelihood of gender-based violence and reduce the quality of life and accessibility of support to women using drugs. Violence is on the rise in quarantine, and access to help from harm reduction programs and from support systems for women experiencing violence is decreasing.

We are in solidarity

Realizing the particular vulnerability of women using drugs in a pandemic, in 2020 EHRA gathered fellow experts on providing assistance related to gender-based violence. Together we share the experience of successful integrated services, together we develop principles and practical approaches for organizing such support. We are convinced that support to women using drugs experiencing violence should be organized taking into account the following principles:

  • Woman’s safety, meeting her specific needs, and the well-being of her children and herself are the main goals of services for women using drugs experiencing violence.
  • A woman – regardless of her drug use experience – should receive adequate support and protection in case of domestic or gender-based violence.
  • Support to a woman using drugs experiencing violence includes a range of services from ensuring the safety of a woman to medical, legal assistance and resocialization.
  • Building partnerships between state and non-governmental services, including harm reduction organizations and services for those who experienced violence, ensures the support is comprehensive, high-quality, gender-sensitive and focused on a woman using drugs, her safety and special needs.
  • Three key steps in combating gender-based violence against women using drugs: 1 – Preventing gender-based violence; 2- Organization of protection and support for women; 3 – Advocacy of changes in legislation and/or practice of its application.

Our partners from 5 countries of the EECA region are building and piloting a system of support to women, which is coordinated with harm reduction programs. They provide daily counseling, referral to shelters and ensure safety, so necessary for women experiencing violence.

We believe that dreams come true

The story of a woman using drugs who experienced violence from Ukraine proves that our dream can come true. Here it is, listen:

“God, what a terrible word, “shelter”… However, I was so surprised when at 2 am they answered my call and offered to urgently come to them. There were no requirements for referral papers, health certificates, or statements to the police. A taxi was called for me and an hour later I was in a place that became close to me.

I needed help and I got it. The first thing they asked me was whether I wanted tea or coffee, or maybe I was hungry… ”. The story was provided by the EHRA partner organization “Convictus-Ukraine”.

We want every woman to get a chance not only to hide from violence for a short time, but also to find her calling and place in life, to gain independence, same as happened with the heroine of this story. Such words are all we need to get inspiration and continue work on improving access to shelters and psychosocial services for women using drugs experiencing violence. Our slogan:

Help, impossible to ignore!

 

More information about the project Access to comprehensive care for women using drugs in case of violence: https://harmreductioneurasia.org/projects/c19rm/.

Drug policy and harm reduction in Southeast and Central Europe

Have there been any significant developments in the region of Central and Southeast Europe since 2018? Any scale-back or scale-up of harm reduction services? 

There are some improvements in some countries, for example, in Serbia, Montenegro and Macedonia. Although governments still allocate very small budgets for harm reduction, at least they are becoming more open, willing to cooperate with the civil society and end this terrible situation after the Global Fund funding ended and other programs collapsed.

There is a new outreach program in Belgrade. The Bosnian government seems to be open to give funding for harm reduction; some money was allocated in Montenegro. The financing in Bulgaria that was stopped due to some bureaucratic problem related to the funding criteria introduced by the government has been resolved to a certain extent now, and the needle exchange program operates again in Sofia, and a new drop-in centre was also opened, which was later closed down.

There is still a shortage of opiate substitution medications in Romania, and the Ministry of Health is very inactive to solve this. Thankfully, there are still available programs even amid the coronavirus pandemic. Organization Carusel has made some significant improvements and recently opened a new shelter.

No real improvements happened in Hungary, apart from a new mobile outreach program in Budapest, called HepaGo, which reaches those areas where needle exchange programs were shut down in 2014. The only problem is that it is financed with international money, which makes it fragile; it’s not sustainable without money from the state. Injecting drug use in Budapest is decreasing, probably because people are switching to smoking synthetic cannabinoids.

More and more people use new psychoactive substances in other Eastern and Central European countries: some of them as the main drug, and some in combination with other substances. I think it is a very significant change for care systems because most of them were primarily constructed to get opiate users into substitution programs. But how do you deal with the treatment of new substances’ users? I’ve heard that rehab programs don’t work for them as well as with opiate users. We probably need to explore these short-term interventions for these users, who are sometimes much younger than heroin users. People still need help, but they need some different approaches.

You said that some governments had become more open to harm reduction. What has changed to make them do that? 

I think the fact that they sit down at the negotiating table is already a good sign. In Belgrade, we presented a study about the clients of a closed needle and syringe program, and the feedback from the government was very positive, they are now more friendly to the civil society and speak with them more actively. They still can’t offer much, but at least they have some budget for harm reduction programs. In most cases, I think this change happens because of the pressure and advocacy by the civil society. But these bureaucratic machines are very slow. After years of advocacy, it gets to the stage when the implementation of programs is in the hands of decision-makers. A few years ago, we formed the Drug Policy Network South East Europe, and it took us two more years until ministries started implementing real measures. 

Are these measures mainly related to the “old harm reduction”, or do they also involve new services, like drug checking or drug consumption rooms? 

Some organisations in Eastern and Central Europe started doing drug checking in nightlife settings and during festivals. In Western Europe, however, liquid chromatography machines are now used in festivals. I think many organisations in our region could also afford them. The real barriers are not financial. Money could be collected through fundraising or crowdsourcing campaigns. There are a lot of wealthy middle-class people going to these festivals. It’s not a big deal to raise the money. I think that the real problems are legal barriers and police practices.

Are these the same barriers for introducing new harm reduction approaches in general? To open drug consumption rooms or change service packages in harm reduction settings? 

In an environment where you don’t even have resources to operate traditional harm reduction services, like needle and syringe programs or opiate substitution, you don’t have funding for anything else. It requires stable, sustainable funding from the government to run these programs. It’s not something you can just start and see what happens. The second issue is the attitude of governments. They don’t want to risk this kind of public controversy. Even in the progressive Czech Republic, conflicts arise with residents who oppose needle and syringe programs. It’s a kind of political risk for leaders in our societies with a lot of conservative-minded people to introduce an innovative program.

You said that because people don’t inject so much, they need different harm reduction. What do you think prevents the existing services from changing their packages?

They are changing. At least in Hungary, they are changing. For example, if there is less demand for needles, they will distribute some other things. At the moment, these are COVID-specific things, like masks, gloves, disinfectants. There is also a demand for social help. Many people are still living with Hepatitis C, and they need help to get into treatment. That’s why we called our new project HepaGo. People who injected drugs before didn’t have access to treatment. This is what this project helps to achieve in collaboration with hepatology doctors.

Psychologists’ help is essential in the case of new psychoactive substances because of psychosis, aggressive behaviour associated with them. Also, most of these people live on the street, and they face a lot of social issues. We should realise that harm reduction is not only about HIV and hepatitis C, but it’s about different kinds of help to people who live on the margins. They need other types of support as well, like helping them to find housing and normalise their social relationships.

You said that some new networks had been formed in the Southern subregion. What kind of networks?

I had in mind the Drug Policy Network South East Europe. They organise conferences for regional harm reduction actors, provide help on the country level, publish reports. It would be useful if people from this and other networks, like the Eurasian Harm Reduction Association, could visit countries to sit down with local politicians, bureaucrats, researchers and civil society. This would provide local NGOs with an opportunity to talk to governments and set agendas. Such a model would be useful in the future after the pandemic is over.

What is the civil society’s role, and what do they advocate for in different countries? 

Budget is still the main issue. It’s a year to year survival for programs, which limits the scope of advocacy because you have to fight for the very resources that enable you to operate. You don’t really have the capacity, energy and staff to fight for other things. The funding for harm reduction in the region is unstable. That is also one of the reasons we don’t have enough innovations or don’t open drug consumption rooms or implement naloxone programs. Governments primarily aim at banning substances and don’t care about providing support to drug users. And I see a lot of uncertainty among service providers in light of these changes in the drug market. The readily available harm reduction models that used to work are not enough.

Who funds the services? Are there governments or other international donors besides the Global Fund that do this in the region?

Most of the funding comes from national or local governments. I don’t know any significant international financing of services coming to the region right now. I know organisations that have conducted successful fundraising or crowdsourcing campaigns. The new drop-in centre in Sofia was opened with the fundraised money. I also know organisations in Hungary that work with marginalised Roma people, not only drug users, who have led some successful crowdsourcing campaigns. It is not a lot of money, not enough to run organisations, especially if they provide lifesaving, public health and social services that the government should fund. Crowdsourcing opportunities won’t substitute the stability of government funding.

Do any organizations advocate for the decriminalization of drug possession, drug use or the human rights of people who use drugs?

There are not that many. There was a decriminalization campaign in Lithuania in 2017, but I don’t remember any others. You need to have liberal or socialist governments to have a successful campaign in this area. I don’t see any countries now where anybody could say that there is at least a 50 per cent chance to lead a successful advocacy campaign in the fields you mention.

But it doesn’t mean you shouldn’t do it.

You are right; it doesn’t. It doesn’t mean that you should not deal with criminal justice and criminalisation of people, because these are critical issues. I see efforts being made to add alternatives to incarceration systems. In Poland, for example, they are talking about more alternatives and also how to link the criminal justice system to the treatment system.

Would you agree that most organisations in the region primarily work on the provision of services and funding, but not drug policy and advocacy? 

I think some organisations do advocacy on top of providing services, and some don’t even understand why advocacy is crucial in the first place. What they do is not always advocacy—they try to make some behind-the-scenes pacts with governments. Only very few organisations, maybe one third, are brave enough to organise campaigns like Support don’t Punish on the 26 of June. Even when they do, it’s sometimes very weak. In general, advocacy is very weak in the region. Only very few organisations do real advocacy; and mostly on funding and services. They don’t want to take the risk of being political to talk about criminalisation. Harm reduction services are much easier for people to swallow than decriminalisation. It’s not easy for many in the government to understand that these people need help; they should not be punished in the first place. We don’t see much of this attitude in the region.

You said that organisations must be brave to do advocacy. What kind of consequences could they face? Will they lose funding if they speak about decriminalisation, or is there more to it?

That’s the main fear. Most of these organisations are very much dependent on government funding, and they are afraid to lose it. I wouldn’t say that this fear is unfounded in the environment of very scarce resources. Governments tend to support organisations that they find more manageable and conforming to their expectations. That’s why there is a need for bravery to speak up for decriminalisation. You can be labelled a “political civil society”, which in some countries like mine, are called “Soros agents” [the Hungarian-born American billionaire philanthropist George Soros finances many liberal and progressive causes] or be accused of wanting to legalise drugs. I think many service providers want to avoid being labelled as a radical organisation.

But harm reduction is mentioned in policy documents and is featured in national health packages.

Many national drug strategies do mention harm reduction. Some countries mention surprisingly progressive things, for example, in some Balkan countries. I’ve heard that some national drug strategies there have been copy-pasted from EU documents. But it doesn’t mean, of course, that these documents are implemented, despite all these references, existing mechanisms for funding or alternatives to incarceration. They are simply not used. Or if they are, not on the full scale. It is not a priority for governments.

But why do they have all these policies but don’t implement them? 

I think it’s a kind of nature of policymaking: it’s much easier to adopt guidelines and recommendations than implement them. Governments can claim success by issuing a new rule or strategy, tick the box of having a national drug strategy in the form of a comprehensive, balanced document. They can tell the media and people, “We are working on a drug policy, we have a strategy”. But they are not so eager when it comes to allocating resources for their implementation. Monitoring and evaluation are also missing in most countries. In Hungary, four organisations working in rehabilitation, treatment, prevention and harm reduction, united in the Civil Society Forum on Drugs. We did an independent civil society evaluation of the implementation of our national drug strategy and produced a report based on focus group research and interviews with service providers. But governments don’t make any efforts to evaluate their policies.  

Could you identify any good advocacy efforts in the subregion? Also, what do you think works when you speak to governments? 

What works very much depends on the attitude of each particular government. For example, Poland has a very conservative government, but at least they have the National Drug Agency, which kind of counterbalances these conservative tendencies, and they can maintain support for harm reduction programs and civil society. The conferences on drug policies that the Polish Drug Policy Network organised in the previous years in different cities was a beneficial civil society initiative to show that drug policy is not only about national governments. Some issues could be solved on the local level. They also trained a lot of municipal authorities and professionals.

Super conservative governments now rule in many countries, but there are liberal city mayors. When the national government is inaccessible, we can go to city authorities. We have been doing this in Hungary, and a lot has been achieved in local governments. Some of them now support harm reduction. One thing we have learned in the past two or three years is that we should focus more on local policies. Harm reduction was born as a grassroots initiative in European cities: Frankfurt, Zürich and others. It has always been a local thing. Possibly, it won’t work in all the Balkan countries, but it does in Hungary and Slovakia. Bratislava has a new city mayor, and Iveta Chovancova, a former member of the Eurasian Harm Reduction Association’s Steering Committee, now works for the city administration and helps promote harm reduction programs from the inside. The next harm reduction conference will be held in Prague, and I see the city also supports this conference.

Could you talk more about the Roma population and drug use in the region. I understand it’s a big problem.

I wrote an article about this some time ago that sums up the scope for this issue. There are large Roma populations in Slovakia, Czech Republic, Hungary, Romania, Serbia and Bulgaria. In Hungary, for example, seven percent of the population is Roma. Most of them are likely unemployed and don’t have access to essential services, suffer from segregation in schools and places they live in.

The situation is similar in other countries with large Roma populations. Even though drug policies claim to be colour-blind, but there is racial profiling in the region. When we speak about this, we usually think about the US and Afro Americans and Latino Americans, but we don’t talk about what is happening in our region. We don’t talk about the trauma of people who have a much greater chance to be arrested for drug use and be imprisoned. You can see in many cities across the region that nine out of ten people in needle exchange centres are Roma. We don’t have enough studies and research about this, but Roma constitute a big part of the poor. Sometimes existing programs don’t reach out to these communities because they operate in city centres, while these people live in segregated areas. And if you don’t have culturally appropriate outreach programs to bring help to their part of the city, you don’t even see them. They become completely invisible. I think we need to work more on this. If we researched how much Hep C or HIV affect these populations, we would indeed find that they are disproportionately affected.

What about other groups, like women or young people or men who have sex with men? Are there any specific services for these groups in the region?

I see very few services targeting these populations. The only needle and syringe program for women in Hungary was closed in 2014. The research on women done last year by Zsuzsa Kaló in Hungary found that the country’s treatment system is not friendly to women and don’t always meet their needs, especially if children are involved. Women don’t have a place to leave their children when they go to services. There is also the problem of domestic violence. If their partners are also drug users, women don’t always want to go to the same service. Women are pretty much dependent on their partner for assistance and getting drugs.

Most specific services target sex-workers. They sometimes overlap, of course. Only one program in Hungary provides shelter and services explicitly for pregnant women who use drugs. It’s similar in other countries, I think. The only exception could be migrants and refugees, which is a massive issue in Balkans now. I’ve heard about programs that go to refugee camps for HIV and Hep C testing or reach out to drug users.

What about young people who use drugs? Do any programs address their needs? 

In my experience, most such organisations are set up and operated by young people who are party drug users. Therefore, all their services are linked to the party scene. I don’t see the same for marginalised injecting drug users. Youth organisations are mostly for psychedelic drug users. I have always admired this organisation in Belorussia Legalize Belarus. In a country like Belarus, it’s impressive. These idealistic young people do good things, but they are not harm reduction service providers.

Let’s talk about some specific services, like the opioid agonist treatment (OAT). Are there any problems with take-home dosages, mandatory drug checks? 

In most countries, maybe except the Czech Republic and Slovenia, the main issue has always been accessing services. But with the shrinking number of opiate users in some countries as Hungary, the situation is changing. Still, regulations are very restrictive. Many people are pushed to detox or are not able to access the type of therapy they prefer, e.g., they are forced to take Suboxone when they want methadone or buprenorphine. Sometimes these decisions are not based on the needs of clients but are dictated by agreements between pharmaceutical companies and service providers. Many clients in Hungary were not happy when services switched from pills to liquid methadone.

OAT programs sometimes feel like very rigid systems that are more serving the people who are providing the service rather than those who receive it. Because of these restrictions, some people opt to get a prescription from doctors to buy the therapy they want in pharmacies. But there are not many of them; only those who can afford this. Most still get their treatment from state- or NGO-run programs. I think that the COVID-19 pandemic can change this rigidness, help break down these barriers. We hear that the rules are changing in many countries now, and people are allowed take-home dosages for more extended periods of time.

Is there any difference in terms of quality of services or clients between NGO- and state-run substitution clinics?

Most state-run clinics I have visited in the region are in hospitals. They are approachable for those who live in cities. With NGOs, it’s a mixed picture, but they are less prevalent. For example, in Hungary, I think only one or two NGOs do that. In most other countries, especially in the Balkans, it is still very much doctors in white coats in hospitals.

Do clients prefer NGO-run sites?

I never asked clients this specific question but think that they would much rather go to a drop-in centre rather than to a clinical, sterile, bureaucratic setting that is not user friendly and has this kind of authoritarian atmosphere. A lot of people are queuing in these hospitals, and there are conflicts. The black market for methadone is a considerable problem in many countries. Dealing happens near these large hospitals. We had a lot of reports about people robbed by some violent gangs after leaving a hospital, who take their methadone. I think it is safer and more friendly to have decentralised OAT centres. It would also be great if general practitioners or psychiatrist could prescribe methadone to be obtained in pharmacies.

Why do you think it’s so hard to scale up these services? 

Again, I think it’s more an ideological rather than a financial barrier. Many governments say that there is not enough money. I don’t think it’s the issue. When governments start to prioritise, they always find the money. But these issues are not something that politicians can gain political capital with; they are not popular. They cannot sell it as a political product. It’s similar to renovating prisons. They can say that money is spent to build new jails to put more people into them, but not that the new jails are more humane for inmates.

Why do you think it’s so politicised? We’re speaking about health issues. 

Because drug use is a moral issue, many don’t perceive it as a public health issue like diabetes. Most people still condemn drug use, stigmatise it. I don’t think this attitude would much change if drugs were legalised. This label would remain because people perceive that it is drug users’ fault: You are morally inferior if you use drugs, and you don’t deserve to receive this funding because you are less than me. I am a normal person, pay my taxes, but you don’t. Why do you deserve more? Why shouldn’t we give the money to kindergartens? Alcoholism is perceived as part of our culture, but drugs are viewed as something alien.

What about barriers to services and their quality? 

As I have mentioned, restrictive rules primarily prevent people from being admitted to programmes. Also, people are often prescribed very low doses. And we know that insufficient quantities don’t work. We have been trying to change this in Hungary for a long time without real success. Some responsive doctors prescribe sufficient doses, but most of them are very conservative, with the abstinence-minded mentality, who push people to reduce their dose. Another issue is limited slots for substitution treatment. Of course, it’s different in each country. In Hungary, if hospitals admit more people, they must cover these expenses from their budget, they do not receive this normative fund from the state budget. That’s why there are waiting lists. People must undergo one or two unsuccessful attempts to quit, and only then they are admitted into programs. But it depends on doctors—their attitudes remain the most significant barrier.

What about polydrug use? If you’re a polydrug user, can you enter the program?

It also depends on the doctor. Some programs require urine tests, and you can be kicked out if you use other substances. A good professional with a normal mindset would not kick out someone just because he or she smoked marijuana. It depends on the professionalism and humanity of doctors.

What about the quality of services? How comprehensive are they? 

Most hospitals conduct motivational interviews for people who want to quit and have ties to rehabilitation centres. OAT programs are often accused of being “pill meals.” But it’s not true. Most programs are making serious efforts. I have never seen an OAT that kicks you out because you refuse to go to group meetings or counselling. If clients don’t need this type of personal interaction and just want to pick up their medicine, they can go to a substitution clinic without having interactions with any other services for years. But if you want, there are possibilities.

Are there groups of OAT clients who advocate for the improvement of the quality and coverage of services?

This area is very underdeveloped, and there are very few groups like that. This is one of the critical problems in our region that service providers don’t make much efforts to encourage community involvement. Mostly because it would need additional financial, time and energy investments. You need to have resources and capacities to do this. Advocacy organisations can’t do this alone. But if you are a service provider, I think it could be done with the training of peer leaders. Some young people organisations are working in the field of psychedelics or cannabis, but not with marginalised communities.

Governments don’t adequately implement monitoring mechanisms. The Czech Republic has some kind of quality accreditation for drug prevention programs, but not for harm reduction. I don’t see any significant efforts to monitor and evaluate these programs.

Why do you think there are no working monitoring mechanisms? It would make sense because the governments fund them. 

Countries have different protocols. But again, it requires money to implement them. The first thing governments should recognise is that it’s also their responsibility to ensure that these programs operate according to quality standards. Professional guidelines in Hungary foresee that each harm reduction program needs to employ at least two half-time workers and a professional worker. There are standards for the professional education of these people. But it is not enough to pay their salaries from the funds the government provides to these programs. It’s a contradiction: the professional guidelines say that you need to have this and that, but there are no resources. When governments don’t provide sufficient budgets for these services, they will not pay attention to the quality evaluation because they know that it is impossible to achieve the standards with existing resources. Harm reduction programs are happy if they can produce base salaries for the staff and for the safe disposal of needles, which requires a lot of money. They don’t have money for extra services, like psychologists or gynaecologists. It’s a resource issue.

Can you talk more about the new psychoactive substances and amphetamine-type stimulants?

The primary stimulant in our regions is still amphetamine. But the new psychoactive stimulants are also coming, especially in Poland, Hungary, Romania. In Slovakia and the Czech Republic, pervitin (methamphetamine) prevails. In Hungary, most injecting drug users use cathinone-type new stimulants. The trend of synthetic cannabinoid use can be seen in many countries: in prisons, among homeless or Roma people. Most marginalised groups massively turn to synthetic cannabinoids because they are cheap, readily available, and they just knock you out: you don’t feel the pain and suffering of everyday life. It’s an “ideal” drug for the poor. These new synthetic stimulants and cannabinoids are dealt with separately, not in one group.

And what about overdose prevention and access to naloxone? 

In most countries, naloxone cannot be taken home or distributed because of the protocols allowing only a professional doctor to administer it. It’s only available in emergency units, and nasal naloxone is missing entirely. I don’t see any real efforts to introduce naloxone, maybe only in the Baltics, in Estonia, not in other countries. When we had the heroin crises about ten years ago, service providers advocated for naloxone, but not anymore. I don’t think that it is a part of any advocacy efforts.

What is happening with drug use and harm reduction in prisons? Is there any new research about these issues? 

The prison issue is still a white spot in most countries. No OATs exist in Hungarian prisons. But even in the countries where they do, access to them is very low. Needle exchange is absent entirely. Most prisons don’t address drug issues at all, sometimes provide some counselling, Narcotics Anonymous or something like that. Prisoners increasingly use new psychoactive substances because it’s much easier to smuggle them in and it is much more difficult to test them. Prisoners were banned from receiving postcards in Hungarian prisons because there were many instances when they were soaked in drugs. Letters to prisoners are now xeroxed. Sending tobacco is also not allowed because cigarettes were often infused with cannabinoids. I think that synthetic cannabinoid issue is the biggest problem in prisons where the use of new psychoactive substances is widespread among the population. The rate of people incarcerated because of drug use in our region is not very high, but laws are very restrictive, sentences are disproportionately severe, and alternatives to incarceration are underdeveloped and underused, even if they exist in laws.

Is there a problem with legal help for people who use drugs and interact with law enforcement? 

In some countries, such as Poland, this is a problem of training law enforcement. The legal framework for alternatives exists, but judges and prosecutors don’t use it. I know that the Polish Drug Policy Network has made efforts to train judges and prosecutors. In Hungary, the law allows people to opt for six months in an outpatient program in the case of small amounts. About 90 per cent of people who are sent to this program are occasional cannabis users who don’t need any treatment. Even if one of these alternatives exists, there are no real filters in place, like in Portugal, when only problematic cases are referred to treatment. There is no need to treat those who don’t need this.

My last question is about hepatitis C, HIV and TB treatments. What are the major problems?

After the HIV outbreak in Romania, we didn’t see more outbreaks in the region. Testing and counselling are still very low, especially in some countries like Hungary. Even if people are tested positive, how to ensure that they go to treatment? With the new hepatitis C treatment, there is some money from the big pharmaceutical companies, which is a positive thing. In Slovakia, they gave some money for harm reduction organisations to help drug users to get into hepatitis C treatment. It also later happened in Hungary. The biggest problem is in those countries where there is no harm reduction, or its coverage is limited, like Hungary or the Balkans, where it is hard to get treatment for these people. I wonder how many people, who were infected with Hep C five or six years ago, will develop cirrhosis or even die needlessly when they could otherwise be saved? This is devastating to see.

How to exhibit about harm reduction at music festival

Harm reduction at music festivals – it is not a new practice for Europe. However, here, in CEECA region, we are just making first steps towards implementation of such practices in condition of criminalization of drug possession and distribution. This year at one of the small festivals in Lithuania, our team joined the initiative and now we are ready to share a few impressions. “Say know” instead of “say no” to drugs was our motto during the YAGA festival, which took place on August 6-10 in Lithuania.

The participants of the festival, regardless of whether they use psychoactive substances or not, were very interested in any information on how to protect themselves and others in different situations related to the consumption and different sexual practices.  What do we need to know to reduce the risk or harm from substance use?

– You need to know what you use. With legal substances, the quality of the product has been tested and licensed by the government. In the case of illegal substances, you can not trust what drug dealers say. Drug testing is a key approach to harm reduction. It would be ideal to analyze the content of different substances in a drug, but so far only a couple of countries in Europe have offered such testing . In the context of the festival, it is possible to carry out reagent tests, when a person can test by himself or herself whether the substance declared by the seller is in a tablet or powder, some tests also make it possible to determine the purity of the substance. After taking several tests, a person will be able to find out if there are any other substances in the tablets.

– You need to know the health risks and consequences of using psychoactive substances in different ways and know remember reduction measures to prevent the risks. EHRA team at the exhibition of harm reduction tools showed visitors what items can help to reduce the health risks of smoking, oral, injected, or rectal use.

– You need to know how to prevent overdose or how to make human life safer in the event of an overdose. And while the use of naloxone is recommended for opioid drugs, there are no such simple overdose prevention methods for stimulants.  

What is important is that the team has agreed in advance with the festival organizers, local authorities, the police, and medical services on all harm reduction activities. Any talk about drugs, peer counseling, or a seminar on drugs initially frightens the organizers, as if the conversation itself was propaganda for use. In Lithuania, the Be safe lab project has been running for several years now at the most popular music festivals, in cooperation with the Drug, Tobacco, and alcohol control department and the Coalition “I can live”. Thanks to this project, festival participants have access to information about the harm caused by different substances, especially if they are mixed, and have an opportunity to receive professional medical (psychological and drug treatment) assistance in case of problems. Such partnership facilitated our activity at the festival.

Information about the safe combination of drugs, harm reduction measures for different ways of use, reducing the risk of overdose, and assistance with the unpleasant consequences of drug use (what is called a bad trip, when psychosis, paranoid conditions, etc.) – these topics mostly were in demand among festival participants. It was important that professional help and support in case of problems related to the use of this drug was available 24 hours a day, 7 days a week right at the festival. Our partners from Demetra during the festival provided the opportunity for those wishing to be tested for HIV, as well as free consultations on safe sex and receive condoms and lubricants.

One of popular spots in the festival camp was EHRA’s equipment exhibition “HARM REDUCTION TOOLS”. The wooden stand demonstrated different examples of the tools used to reduce harm was placed with short explanation – for what drug is it used and what health harm it could prevent. Different drug use equipment like smoking kits, snorting kits, booty bumping, tools for oral administration of drugs, injecting equipment, reagents for the drug checking were presented. 

In total, around 15-20 different tools from traditional needles and syringes, condoms and lubricants to overdose preventing medication such as nasal naloxone, other tools of safety such as tests for drug checking and gelatine capsules. During several hours per day one of the EHRA volunteers guided festival participants on what was presented on the stand as well as provided with additional explanation on harm reduction approaches and tools used all around the globe and in Lithuania.

The idea with harm reduction exhibition worked out well, a lot of people came to the stand, listened to the "lecturer", asked questions and took reagent tests and gelatine capsules. People said that they feel "enlightened" and that this project is very useful and important. Our colleagues from Demetra and Be Safe Lab also learned a lot and proposed to repeat this exhibition at future events.
Maria Plotko
Senior Program Officer, exhibition co-creator

Also this year EHRA team organized a seminar “Sex, Drugs and Harm Reduction” to tell festival visitors more about harm reduction, safe use of psychoactive substances and about protection in “chemsex”.

The last but, not least initiative was the distribution of reagent tests for those who wanted to check psychoactive substances. This action was important in term of local approach to the harm reduction as in Lithuania on-site drug checking is not allowed (criminalized).

Despite the late hour quite big group of people came to the workshop on Sex, Drugs and Harm reduction there was a problem with loud music and no lightning but people stayed anyway, surprisingly asked a lot of questions about naloxone
Maria Plotko
Senior Program Officer, exhibition co-creator

Harm reduction during music festivals and events, introduction of harm reduction tools for non-injection use into harm reduction programs, integration of substance testing in CEECA countries – all these tasks are faced by EHRA in advocacy. Based on the practical experience of consulting during the festival, the team will act more effectively in future activities.

It was a pleasure for the EHRA team and for me personally to hear from young people from around the world, Lithuania, Poland, Latvia, Estonia, Finland that our exhibition of harm reduction tools was useful. Many people, while looking at simple tools, immediately discussed how and where to buy gelatin capsules or substance tests. Health and safety are very important to everyone we talked to, and harm reduction programs are an opportunity to know and understand more about your safety and well-being. It is a pity that harm reduction organizations in the Eurasia region rarely have the full range of resources to help people who use drugs. Sometimes there is nothing else but a simple syringe, condom, and HIV information material. But the topic of quality and range of harm reduction services in our region is definitely much broader than our visit to one music festival with an exhibition and seminar.
Ganna Dovbakh
EHRA Executive Director

“Support. Don’t Punish” WHAT HAS CHANGED ON THE HORIZONS OF DRUG POLICY?

Author: Eliza Kurcevič

In 2017, Lithuanian legislators decided that the laws related to the possession of psychoactive substances needed to be tightened. And by taking such a step, they turned the “war against drugs” into a “war against the people”. Why did it become a war against the people?

Continue reading ““Support. Don’t Punish” WHAT HAS CHANGED ON THE HORIZONS OF DRUG POLICY?”

When a tank is urgently needed to transport… methadone to hospitals

Author: Olya Belyaeva, Advocacy Manager, EHRA.

A tank is urgently needed! It doesn’t have to be a new one. The tank is needed to transport methadone to hospitals in Kazakhstan. Drug control authorities require paramilitary security for the transportation of drugs. However, the state is not going to allocate funds for security measures and this issue has not been resolved in 10 years.

Continue reading “When a tank is urgently needed to transport… methadone to hospitals”

The Magic Bracelet

Author: Olga Belyaeva, Advocacy Manager, EHRA

When I heard someone knocking on my hotel room’s door and shouting “She is dying!!!” I was in the bathroom. Just five minutes ago, I entered my room, took my coat and shoes off and… ran out straight away with Naloxone.

After that memorable meeting in Scotland, I carry it with me all the time.  

Glasgow. July 2018. My 45th birthday. “You know, we have a very serious problem with overdoses – those were almost the first words I heard from Stephen Malloy, part of the team of the European Network of People Who Use Drugs. I nodded and a routine though came across my mind: “Back at home, in Vilnius, up to 12 people are found dead in bad months. Under the guise of heroin, people are sold a mix of morphine and methadone together with fentanyl.”   

Looking at me attentively, Stephen went on: “My country has done very well with offering OST (methadone, buprenorphine) but everyone knows more MUST be done. People need easy access and doses that are suitable to them. There will be a small ‘Heroin Assisted Treatment’ program beginning in September 2019. and in time, if it is allowed to grow, it will change so many lives for the better; IT WILL SAVE LIVES.”

So here it is,” Stephen was holding an oblong narrow yellow box in his hand. “Are you ready to take it with you?”  I recognized it: once I saw such a box at a conference. It was convenient and stylish, with Naloxone inside. I said “Sure!” and took the box. “Then put this bracelet on. People will know that you have naloxone with you, if you overdose and they find you. They will be able to help you and you will be able to help others.”  Stephen watched me carefully, assessing my decision: was I really ready?

I put the bracelet on, found a place for the Naloxone box in my belt bag, where I already had my wallet, my phone and my beads. Then I continued my three-day work at the meetings on overdose response.

One of the meetings was dedicated to the topic of 48 hours after prison. There was a discussion with the experts in overdose theory on what should be done first: Naloxone injection and then artificial respiration or first artificial respiration and then Naloxone? My logic told me that first Naloxone is to be injected, which will help to ensure artificial respiration. “That’s a question of life, so it needs a correct answer. When I go to Ukraine, I will have to go and visit Vasiliy, he is an emergency doctor in the city of Dnepr. He saved my life more than once, so I believed him. He will tell what is to be done. He will also teach me how to do it,” I was thinking, packing my things to go to the EHRA headquarters in Vilnius.

Railway station. Stephen and Nicole’s birthday present – Scottish red and green check scarf – kept me warm. Standing at the platform, we gave each other goodbye hugs, listening to our heartbeats.  Making myself comfortable in my seat with a book, I realized that my eyes were constantly coming back to the yellow bracelet.  The sounds of the train, its rhythmic swing combined with polite and quiet travel companions – it all gave me a chance to think why it happened like this: I had 30 years of opoiod use behind me, but Naloxone became part of the things I always consciously carry with me only three days ago.

Why? With the daily use of opiates, which were cooked correctly using high-quality materials, overdoses were rare in our group. Usually they happened after the forced “treatments.” Since about 2005, if you hear someone had an overdose in Dnepr (Ukraine), the response would be: “He was lucky to survive.” Naloxone ampules were available in mobile clinics and from outreach workers since 2003. However, it was the first time in my life when I wore a bracelet saying “I have Naloxone.” We always tried to avoid carrying Naloxone ampules with us so that the police would not start working on us because of it: “Hey, Naloxone, so you’re a drug addict!” Then the standard scenario would follow: taking a bribe and letting us go for a while. Another scenario could be turning the life of the person and the family upside down, if they needed to show better “crime detection rate.” Quietly and invisibly, the bracelet started raising my level of consciousness about overdoses.  It became a part of me. I only take it off when I have my aikido practice. The rest of the time, I have the bracelet on my arm, which means I have Naloxone in my bag and my bag – on my belt.

The approach to have Naloxone “always at hand” helped me to save a person’s life at the hotel. I covered three floors – and 40 seconds after I heard someone knocking on my door, Naloxone was already doing its work in the body and helped us to keep our dear friend alive. We did artificial respiration, poured water, and our team of two people + naloxone helped to save our friend’s life. We prayed for Stephen and Nicole. I realized that I do not have practical reanimation skills, which work automatically. At the same time, wearing a bracelet saying “I have Naloxone” means that I have to be 100% sure about the things I am doing. So I still had the question: what should come first – Naloxone or artificial respiration? My trip to Dnepr was not coming soon, but the question was vital. So we invited a practitioner, an emergency care doctor to come to the EHRA office, share his experience and tell us what to do.

“After death, pinned pupils are seen only in people who died of opiate overdose. Sometimes it can also be an effect of cerebral hemorrhage, but in this case one pupil is constricted and the other is not,” told us an emergency care doctor from Vilnius. That is how easy it is to collect data and see how many people actually die of opiate overdose, who those people and their family members are and what can be done. Those are the things to be done:

First, 70% of people die as they are not able to breathe. When a person is unconscious, his tongue base goes down and closes the air passages.  What to do: put your hand on the person’s forehead, throw the head a little back and put the jaw down. Often you will hear a deep breath.  There are three ways to determine if the person is breathing: eye, ear next to the person’s mouth and watching the person’s chest. With your eye, you will always feel the air moving, with your ears you will hear it and the chest will help you to see it. A person makes 14-16 breaths per minute. So we wait for 10-15 seconds to see if we can hear or feel the person breathing or see the chest moving.

Second, we must fill the lungs with oxygen. “While an amputated limb or finger can be stitched back to the body even after three hours, a brain cell left without oxygen for four minutes, dies and this process is irreversible.” We breathe in 21% of oxygen, breathe out – 17%. So that’s what we need to do straight away: hold the nose and carefully breathe the air into the person’s lungs twice. This air will be enough to save the brain so that we have four minutes to inject Naloxone and ensure artificial respiration.

Third, make an intramuscular injection of Naloxone.

Fourth, artificial respiration: we press the chest 30 times and let go, going 4-6 centimeters deep, while breathing. You can watch the practical learning session by the emergency care doctor.

…Summer 2019. “Thank you, Stephen. Girls from the Narcofeminist movement and your Naloxone saved my friend’s life. As for the bracelet, it is a magic one. It helped me realize that I need to develop my skills to help people in different overdose scenarios.” When we met at the Harm Reduction International conference in Porto, we hugged each other tightly, not letting go for a while. 

Besides, I realized that consciousness means personal responsibility in action. People in our countries cannot carry Naloxone safely as they may have problems with police. Considering this, talented Sergey Bessonov and Dima Shvets came up with a way of how to make boxes and Naloxone packs, which are convenient to keep in a glove compartment in a car or at home. There is even an “excise label” to store the box until there is an emergency. They make those boxes for people, with love and understanding. They are stylish, nicely sized and pleasant to hold. Such boxes are made in the social dormitory of Ranar Charitable Foundation in Kyrgyzstan.

The yellow box, which came to me from Scotland, has already renewed its stock of Naloxone and now has other helpful things as well. The last thing I got from a friend of mine were tablets, which help in case of MDMA overdose.  In the center, there is a syringe with Naloxone. 

If someone needs help, I am ready.

“90% of successful reanimations are the ones when someone did something,” says the emergency care doctor.

 August 30-31, 2019

Kestutis Butkus: “The most important thing for me is not the decision of the Lithuanian court or the ECHR, but the fact that my case resulted in the passing of a law on the provision of OST in Lithuanian prisons. This is a real victory. Our common advocacy driving force.”

EHRA presents a series of conversations with people whose names and roles in harm reduction are well known in the region of Central and Eastern Europe and Central Asia, and beyond. They will share with us the most valuable – their experiences, thoughts, memories.

Kestutis Butkus is a well-known activist, one of the first from the community of people, who use drugs in Lithuania. 8 years ago, his right to health was violated by non-provision of opioid substitution treatment (OST) in prison (at that time, Lithuania remained one of the few EU countries where OST was inaccessible to people in prisons). Kestutis chose the path of struggle against the system and not because of, but rather in spite of, became one of the few (alas), who managed to influence the Law. Since 2018, opioid substitution therapy has been introduced in Lithuanian prisons, but we need to remember – this is only the beginning of a long way*

– What were the circumstances of your arrest in 2011?

– Eight years ago, police “apprehended” me by accident – they found a couple of grams of marijuana in the car. I had several outstanding fines at that time and the judge decided to sentence me to forty-five days in detention so that I would fully comprehend my crime. “Let him lie down and think,” she said. At the trial, I mentioned the methadone program, as I had been receiving substitution therapy for ten consecutive years, to which the judge’s reaction was: “This is outside our competence”.

– Wow. Did you agree with that ruling?

– I appealed, but my appeal was prepared by a person without a license (it used to be possible to do it that way) and then I was put on the wanted list. I didn’t know anything about it. Then one day I came to the migration services to collect my passport. First, they locked me in a room, then a convoy arrived and escorted me to prison. First to pre-trial detention, then to Lukiškės (a prison in Vilnius – comment by EHRA). During all that time no one really explained anything to me. I started writing letters – asking “what for”? There was no answer. Then I found out that those were the forty-five days of detention. It turned out nobody actually read my appeal, they didn’t even consider it. The court ruling came into force, which meant I had to be in prison.

On the first day of the detention, a doctor came to examine me, and I asked for methadone. The doctor, whose name was Mendelevich, said: “You’ll find it very hard – we don’t have a program here. I can only transfer you to the prison hospital, but everything is the same there, except that the ward is more spacious, and smoking is forbidden. You still won’t get methadone though, I can only prescribe “cockroaches”.

– What is it?

– We call light psychotropic substances “cockroaches”. They’re prescribed to everyone so that people can withstand imprisonment, but they have nothing to do with substitution therapy. I began to write appeals, requests, but there was no response.

– Do you remember the prison conditions well?

– Lukiškės is an old prison, it was built in the XIX century. At that time, it was considered one of the most modern in the Russian Empire (at that time most of Lithuania was under the Russian rule — comment by EHRA). These days however it falls short of the standards provided at similar institutions in the European Union. The cells are cramped, for four, there is a table, a washbasin and a toilet. Restriction of freedom is in itself a terrible thing, and those conditions make it simply indescribable. The first eight days were awful. I couldn’t sleep, I started suffering from claustrophobia, though I never had it before. I only managed to get through those moments because I could see a piece of the sky and some rooftops through the bars on the window. I was also lucky to have just one other inmate in my cell, not three (my neighbour was also from the community, by the way, but by that time he had gone through withdrawal).

– Did you spend your entire detention in Lukiškės?

– After eight days I was transferred to another prison – Provinishki (80 km from Vilnius – comment by EHRA). Once there I also immediately mentioned that I was on substitution therapy. The doctor’s answer was: “Don’t complain about your addiction. It’s dissoluteness, not illness.” I understood everything… I said: “I don’t need anything. Just prescribe me some aspirin to thin the blood” (I have a heart valve). They gave it to me, along with “cockroaches”. I was left in a one-person cell for fourteen days. All by myself, having bouts of insomnia…

– Did anyone know you were in prison without access to methadone? Were you allowed to have visitors?

– I was allowed to see a lawyer for the first time in Proviniski – my ex-wife contacted Emilis Subata (Dr. Emilis Subata, Director of the Vilnius Center for Addictive Disorders). He in turn contacted the “I Can Live” Coalition (Vilnius, Lithuania), as I was their member. They managed to hire legal protection for me. Then we thought that this incident could set the wheels in motion for the introduction of OST in Lithuanian prisons. At that time, civil society had been trying unsuccessfully for more than ten years to discuss the matter with the prison department of the Ministry of Justice.

– What measures did the solicitor take?

– He prepared a petition to the prison authorities demanding that they provide me with methadone and requesting a written reply. As a result, a psychiatrist came to see me … (Interestingly, it was only then that I learned that such a specialist was available in prison). He began to reason with me. I said: “Don’t talk, give me a letter.” It was exactly that that acted as a “catalyst” for the whole process. When I was released forty-five days later, the Coalition’s human rights lawyers read the prison’s reply and confirmed that it could be used to refer the case to court, and that we had a chance to overhaul the system. As for my condition… I couldn’t return to the substitution program for a year after my release. I thought I had dealt with withdrawal and that I was able to pull through but I was wrong. I often left the city to see my friends or went to the forest — I didn’t want my daughter (she was still a teenager then) to see what was happening to her dad.

– When did you manage to become stable?

– It was only after a year that I was able to return to the program. That’s when my “marathon” started. First, we went to the local court – they ruled against me. Then we went to the district court, then to the Appeals court – with the same result. Six years later we reached the Supreme Court.

What was the ruling?

– Same as before. That’s why we wrote to Strasbourg, to the European Court of Human Rights (ECHR). The court looked into our case, registered it with a number and accepted it for consideration. The ECHR works according to the following procedure: there are two Chambers. The first one determines whether all opportunities have been exhausted at the national level (in our case it was a yes). And if so, transfers the case to the second Chamber. As soon as that happened, the Lithuanian State literally “woke up” – representatives of the Ministry of Justice, the management of the two prisons I had been in, and the Ministry of Health. Six years on, the Ministry of Health suddenly “remembered” that they had a damage recovery commission, which was to be contacted no later than two weeks after an incident. Of course, I had not contacted the commission. I filed an appeal to the Supreme Court of Lithuania for a retrial based on that fact. It stalled the whole process.

– What was the reaction in Strasburg?

– The ECHR wrote to my lawyers asking what was going on. Lawyers reported that the Ministry of Health had taken the case to court. Upon learning that Strasbourg suspended the case pending clarification.

– Circles of Hell all round…

– Another year went by. In 2018, the Supreme Court acknowledged that I was the injured party. The damage caused to me was estimated… at three hundred euros, plus a bit more for the lawyers and redress – the court admitted I had been right. We appealed those three hundred euros – the court added another thousand on top and just over a thousand for my defence. However, after talking to my lawyers, I decided not to stop there and filed an appeal to Strasbourg over other violations – conditions of detention, standards of hygiene and size of the cell. In the West, such conditions constitute torture.

Last summer, Strasbourg accepted my case. Based on international case law, the lawyers requested thirty-five thousand euros in compensation. And I want to add – that is not a huge amount. There were similar cases in Poland and the UK, where the compensation was about a hundred thousand or more.

– If ECHR rules in your favour, who’s going to be liable for compensation?

– The state. To be more precise – the Justice Ministry. The most important thing for me however is not the decision of the Lithuanian court or the ECHR, but the fact that my case resulted in the passing of a law on the provision of OST in Lithuanian prisons. This is a real victory. Our common advocacy driving force.

– That is, from now on, if someone in need of methadone is put in jail, they’re going to get it there?

– In prison, remand prison, temporary detention facility – everywhere. The law applies to anyone detained for two or more days. There is a catch though. Only those who are officially enrolled on the OST program can receive methadone. We won’t leave it as it is though – the community is putting pressure on the prison department writing letters asking to amend the law and I hope we will be heard.

– Why do you think it took the prison department years to resolve the issue of access to life-saving treatment in prisons? Ruining hundreds of lives along the way – of those who didn’t dare to stand up to the system. Was it money?

– The prison department have a healthcare department within it. And the healthcare department thought that introducing OST in prisons was a very complicated and costly process. They argued that they needed millions to do it. I remember another argument of theirs – where would they keep methadone in prison, it requires special storage conditions! Where else if not in prison! What could be easier than designating a room and installing a methadone dispenser! Implementing the program did not require any significant funds. Who knows though, maybe the prison department just wanted to get some extra money from the Justice Ministry? They are like a state within a state, aren’t they – they report to it but at the same time are independent. They even have their own special internal system, ranks and epaulets.

– It’s like an iceberg then – you can see the reasons that are at the top, that’s 10 per cent, but there are more issues underwater which account for the remaining 90 per cent of barriers.

– I’ll give you another example. They opened the so-called rehabilitation centre for drug users at a prison in Alytus (town in Lithuania – comment by EHRA.) They constructed a building for it especially, furnished it with everything new. Guess who’s moved in there? The entire bunch of the prison’s top dogs, inmates who have nothing to do with the rehabilitation program. Furthermore, they were selling drugs from there for a few years. You think the prison authorities didn’t know that? After all, it’s no secret that drugs are available in prisons at crazy prices. How could such amounts of drugs filter their way into institutions without some help on the inside, from the staff? –

The introduction of the methadone program has slashed the numbers of paying “clientele”. Therefore, my answer about the reason for such a disastrous delay in the implementation of OST in prisons sounds simple – “not profitable.” And I’m happy that my case managed to break the deadlock.

* – According to the Report by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 2018: “…at Alytus, Marijampolė and Pravieniškės Prisons… Opioid substitution treatment was still not available in prisons visited. As in the past, methadone maintenance treatment was continued for persons in police custody but discontinued after their transfer to a prison. Further, there was still nothing on offer in terms of harm reduction, such as a syringe and needle exchange, distribution of condoms, etc.” https://rm.coe.int/168095212f