Walk through the streets of central London and you are guaranteed to pass small, white vehicles, tucked discreetly into side streets. You are unlikely to have noticed these vans. They have a strange invisibility to passers-by, unless the passer-by is a drug addict. He will not only see the van at once but for him it is the only vehicle on the street.
These are mobile needle exchanges. Present yourself at the window and you will be provided with a pack containing sterilised needle, syringe, wipe… everything you need to inject, in fact, except your drug of choice. This you must buy on the street. Funding a serious addiction might cost £300 per day and few addicts have legal access to such money. The substance inside the clean syringe provided by the taxpayer must be bought from the proceeds of crime against the taxpayer. Most of it petty, some of it violent, all of it expensive to society.
It is easy to see, then, why Russia regards needle exchanges as a moral problem and has been unenthusiastic about their introduction. Western organisations are concerned by this. Needle exchanges can have a dramatic effect on the spread of HIV and its more insidious and much less treatable brother, Hepatitis C. But no one can allay Russian concern that supplying addicts with clean needles and syringes amounts to an official nod at an illegal activity – drug taking - which is usually funded by further illegal activity – street crime.
Needle exchanges are perhaps the most accessible face of the current approach to drug addiction. Harm reduction is the buzzphrase. Harm reduction is a development which is not new but newly fashionable in drug treatment in Europe, the USA and Australia. Western aid agencies are puzzled by Russian reluctance to jump on board the harm reduction bandwagon.
Harm reductionists say that the addict, like the poor, will always be with us. The approach takes state acceptance of illegal drug-taking to a new level by not only acknowledging addiction but enabling it. When harm reductionists supply clean needles they are accepting that the addict will continue his drug-taking but inviting him to do so without contracting or spreading needle-borne disease.
But the philosophy can be stretched a lot further than that. It can be stretched to the drug itself. Harm reductionists believe that opiates or opiate substitutes, usually methadone, can be offered to addicts in a controlled, clean and clinical fashion. Considerable statistical evidence shows that such programmes allow many addicts to move off the streets, away from disease and out of crime. Their lives become less chaotic and the calm administration of the drug they need in adequate quantities means that a more regular, controlled family life becomes a possibility. Harm reduction is now adopted as the most realistic approach to addiction by the United Nations, the World Health Organisation and governments throughout the developed world. But not in Russia.
A Westerner (he asked me not to name him) who is working hard in Moscow to overcome this resistance at policy level could not hide his frustration: “Russians will put up any barrier they can to harm reduction. For some years now, they’ve been trying to say that their federal laws don’t allow the administration to offer methadone. Actually, I read the law, went through it with a toothcomb, and was able to prove that this is not the case. There have been times when I have had to point to European Court of Human Rights rulings. And I’ve also taken apart smaller local regulations to prove that at every level Russian law has the flexibility to allow methadone programmes. But if I prove there are no legal barriers, Russians always find other barriers to block harm reduction. They simply refuse to accept a form of treatment which has been adopted in most other countries because the evidence shows that it works.”
Why do Russians insist that harm reduction won’t work in their country? The aid worker wrings his hands. “They read the evidence and then they say: oh, but you don’t understand that Russian addicts are different. This doesn’t apply to us.” Such a retort may be familiar to anyone who has worked in virtually any field in Russia but this aid worker remained undaunted.
It is hard to estimate the number of Russian drug addicts because gathering statistics about chaotic lives in a uniform way across eleven time zones has so far proved virtually impossible. Human Rights Watch says that, in the country of 143 million people, there could be between three and six million users although it is unsure how many of these are addicts. But it is universally agreed that the drug of choice in Russia is heroin. Its journey from Afghanistan is well-documented. Although Western addicts tend to start by smoking heroin, graduating to injection to make their money and their drug hit further, Russians leave out the smoking phase altogether. For them, heroin is a drug to inject. And while many Western heroin addicts seek their high with other substances, most commonly crack, they use heroin’s gentle embrace to bring them back down kindly. Russian addicts seek out heroin for its own sake. Astonishingly, the crack epidemic has, so far, not reached Russia.
How methadone works
Heroin wraps itself around its user lovingly, insulating them from physical or emotional pain. After taking it a very few times, for some people only twice, when the pleasure wears off alarming symptoms occur. The user is relieved to discover that there is a way to free himself from these symptoms: by taking some more heroin. It is a myth that the addict gets a high or a thrill. Simply, by not taking his drug he becomes very ill. He must use it not to feel good but to feel normal.
An addict attempting to stop taking heroin shakes, rattles, aches and vomits. Methadone is a substance which can alleviate these withdrawal symptoms. It is a sugary, green, sticky liquid which looks disturbingly like the popular over-the-counter cold remedy, Night Nurse. Unlike Night Nurse, methadone can be lethal. It alleviates the withdrawal symptoms of the heroin addict so successfully that the addict rapidly develops a whole new addiction to methadone, sometimes while retaining his addiction to heroin. A popular belief among drug users is that coming off methadone is a much harder and takes much longer than coming off heroin. And as a result, most don’t. Few harm reductionists delude themselves that an addict on a controlled methadone programme is likely to leave it behind altogether. But another addict on the programme is another addict off the streets, no longer causing crime or spreading disease. Methadone programmes tick a lot of boxes when statistics are being compiled. No wonder that, in the UK, 74 per cent of drug addicts in treatment are now receiving prescription drugs
“And that’s another thing!” cries the frustrated Western aid worker. “We’ve had any number of papers translated proving how successful methadone programmes have been all over the world. We’ve introduced Russian drug experts to their Western counterparts and taken them to conferences where they’ve learned all about the success of harm reduction. They nod a lot. They go home. And they don’t do it! There’s still no methadone in Russia! What’s their problem?”
The abstinence alternative
Mark Johnson is British and doesn’t know any Russians but he knows why they feel an instinctive moral repulsion for the methadone programme, because he shares it. For much of his life Johnson was certainly classified as one of those hopeless addicts whose chances of ever leaving drugs behind were slim to non-existent: an ideal candidate for harm reduction although the term was not in use when he last went through rehabilitation nine years ago.
Johnson followed the system favoured by the Russians. Not reduction but abstinence. Not treatment but recovery. Against the 74 per cent of treated addicts receiving prescription drugs in the UK, he was one of just 2 per cent offered a residential abstinence programme. Aged 29 and after an addiction which had lasted, in different forms, since childhood, he went through residential detox, a strictly drugs-free month of hell. He then moved on to three months of primary rehabilitation, during which he was taught how to sleep in a bed again (he had been living in doorways and parks in central London for a year), wash, get up in the morning, cook and lead an ordered, less chaotic life. Three more months of secondary rehab followed, when he undertook extensive group and individual therapy and began to follow the Twelve Step Programme.
Narcotics Anonymous, Cocaine Anonymous, Alcoholics Anonymous and many other fellowships follow the Twelve Steps, a programme which is hallowed by those who have completed it. It involves frequent and ongoing participation in meetings where addicts receive the support of other addicts. It demands commitment to helping others. It requires the addict to re-evaluate his life with humility. It invites him to adopt a moral code and then live by it.
Against all predictions for such a hardened addict, Johnson did not relapse. He went on to start his own business and social enterprise, for which he won awards. He wrote a best-selling book, Wasted, about his life as a drug addict, describing his transformation. Johnson then found himself advising the voluntary sector, the prison service and many more branches of Government about addiction and crime. Operating at the highest levels in the criminal justice system, he finally founded his own charity to give a voice to the UK’s most marginalised and excluded citizens, that is, addicts and offenders.
But the method which worked for Johnson is becoming less available. UK rehab budgets are being cut to favour spending on methadone prescriptions instead. Between 1994 and 2005 these prescriptions increased by almost 90 per cent in the UK and became the cornerstone of national treatment policy, a development Mark Johnson views with concern.
“I find the methadone programme frankly disgusting. It was no surprise to me to learn that it originated in Nazi Germany. A civilised society should be asking itself why people need to put chemicals in their veins to change the way they feel. We should be addressing the emotional deprivation, neglect, abuse and dysfunctional childhoods which lie at the root of addiction and we should be doing that through rehabilitation and abstinence and support programmes, not by fostering further dependency.”
So what works?
Johnson in the abstinence corner would like to be able to point to statistics which prove his case, but there aren’t any. It would be much easier to chuckle at Russian drug treatment statistics if our own were in order. However, true comparisons of different treatment systems are virtually impossible on current analysis. When the UK Drug Policy Commission took a hard look at drugs policy in jails it found that, although expenditure is high: “We know remarkably little about what works and for whom.” Any measurement of success in drug treatment terms is hotly contested. The National Treatment Agency for Substance Misuse calls getting and keeping addicts in treatment (which usually means on methadone) for twelve weeks a measure of success. Others define success as a drug-free period but how long should this period be: a month, a year, or fifteen years? So the debate remains largely unsupported by meaningful and comparable statistics. And are statistics showing a decrease in crime but an increase in drug use really the statistics we want?
Dr David Best, former lead researcher at the National Treatment Agency and now a Scottish academic, says that writing out methadone prescriptions is too easy and convenient a substitute for helping addicts really address their problem: “It has strangled choice, starved the field of hope and created a depersonalised processing system which has made it harder for people to seek help [towards abstinence].”
Neil McKeganey, Professor of Drug Misuse Research at the University of Glasgow, commenting on a heroin substitution programme, says: “Treatment should fundamentally be about taking people off drugs. It should be a response to their circumstances rather than a crime reduction measure.”
The abstinence debate may have found unexpected support in Russia but, as usual, practicalities trample all over moral philosophy. Russians may believe that detox, rehab and recovery is the way for addicts to move forward but in the face of their burgeoning problem they are doing little to offer addicts this service. In 2007 Human Rights Watch published a report which identified Russia’s failure to do so as a human rights violation. While the report’s fury is aimed at Russian determination to keep methadone programmes out, it also points out that: “Detox treatment is widely available throughout Russia but rehabilitation treatment remains unavailable in many parts of the country. Various obstacles keep drug users away from seeking treatment at state clinics, including the risk of restrictions on civil rights by being registered as a drug user, breaches of confidentiality associated with treatment, and a widespread distrust of drug treatment services that also undermines take-up rates.”
It is easy to understand the fury of Western aid officials who helplessly watch Russia’s addiction rates rise and the number of HIV-carriers reaching one million. They believe they have a sensible pragmatic answer to the crime and illness which explodes in a drugs-infested society only to be told by Russians who fail to implement their own solution effectively that the Western answer is morally unacceptable.
But there is no need for the debate to be so polarised. Most experts agree that methadone has a role to play in national drugs treatment policy but many believe that role should be a part of a much broader system of psycho-social support. And maybe that psycho-social approach is the key to harm reductionists’ suspicions about Russia’s preferred treatment. Mark Johnson describes the process: “I was basically taken apart and rebuilt. Intensive one-on-one and group therapy restructured the way I had been thinking and feeling since childhood. Drugs were a way of avoiding the pain. Now I had to face it and reconstruct myself. Since then, the Twelve Steps have kept me on this path and helped stop me from reverting to my old self and relapsing.”
Hmmm. Rebuilding your personality into something more socially acceptable might be fine in Britain but in Russia it carries the unmistakeable whiff of Sovietism. Harm reductionists can’t help suspecting that old Russian thinking is holding the country back from the exciting new developments they offer in drugs treatment. But perhaps the truth is less sinister. There is a battle over the right way to treat addiction in the west and we have taken that battle onto Russian soil. The Russians are watching us slug it out. But, for now, they’re not joining in.
Elizabeth Rigbey is a freelance journalist and writer