Great success of small grants. En route with methadone. Part 1

13 January 2016

Surprisingly, while in one country people living with drug addiction literally line up to get into methadone programs (MT), create the "wait lists" and even organize events to express dissatisfaction with the officials’ truly murderous slowness (" Your lines kill us! "- say in despair Ukrainian drug users) - at the same time in another EECA country, Latvia, opioid substitution treatment (OST) patients themselves do everything possible to attract new clients to OST programs. In connection with this, it will be very informative and useful to talk about the experience of the initiative group "Doors" organized by the Riga MP patients, the  winners of the Small Grants Program of the Eurasian Harm Reduction Network “Through Peers’ Efforts -2".

 …Latvia was one of the first countries in Eastern Europe that started substitution treatment of opioid dependence with methadone (in Latvia it happened back in the year 1996). And in 2005 buprenorphine pharmacotherapy was officially introduced.

Today in Latvia, a country with the population of 2 million people, estimated 5 to 13 thousand people use opiates. However, no more than 3% of them receive treatment. Only 1 to 2% of all people for whom this treatment can be effective participate in the methadone treatment program. This is the lowest participation rate in the EU. The norm in Latvia would be to provide methadone to 15 - 20% of people who use illicit opiates throughout the country.

Thus methadone program is available in 10 cities across the country and there are two methadone treatment sites in Riga.

By the end of 2014, 222 people received methadone and 102 people- buprenorphine in the capital of the republic. During the current year, 58 new patients received methadone treatment, and 46 patients were prescribed buprenorphine. 12 people receive methadone and one receives buprenorphine in  prison settings. By the way, there are no problems with the Interior Ministry and OST at the moment in Latvia.

Juris Eksshteyns, the leader of the initiative group "Doors", talked to us about the current situation:

- The group "Doors", as the initiative group of opioid substitution therapy patients (hereinafter - OST), was formed in 1996 with the beginning of a methadone program in Latvia. We all met in the program and we are all OST program clients.

- So, it happens that you have been on methadone ... for almost 20 years!

- And not just me. Since 1999, we have already begun to work in the syringe exchange program (and still work there). In the cities of Riga, Ogre, and Olaine.

- Cool. And how do "Doors" do, how often do you meet?

- We meet at least once a month. Basically, we meet to mark personal events, discuss the current situation in harm reduction, make suggestions for improvement, share information and help solve all sorts of personal everyday problems. Having carried out the first EHRN project, our group became known at the regional level, and we began to receive more interesting information, which now has to be discussed. I, as the leader of the group took part in the regional forum PUD in Chisinau in May 2014. Today, speaking the official language, our group mobilizes to participate in advocacy activities, participates in surveys, collects information, participates in public actions of society "Union HIV. LV“. What else to add? All members of the group are people who use drugs. 9 have HIV positive status. 17 people have been OST clients for many years.

By the way, the group size increased to 23 people since 2014 when our group implemented the first EHRN small grants project Network “Through Peers’ Efforts -2” to assess the quality of harm reduction services. After joining the group “Doors”, new members became a link in the secondary exchange of injection equipment. A significant amount of needle exchange is done through our volunteers who are active drug users.

- What results of your activities would you call the most successful?

- In fact, all the work that we do, is done well. But perhaps the most important thing for us was opening the second OST site – a methadone program on the left-bank part of Riga. But still there are not enough state-funded places in the program, and our group helps people get enrolled in the OST program. In particular, we have already helped five people who use drugs. Maybe the wishes of patients were in line with the wishes of the Center for Disease Control and Prevention and drug treatment hospitals, responsible for the OST, but we really did not expect that there would be such great results.

 - How are your relations with staff on the sites?

-  All goes well. Previously, of course, there were some problems, but now really all is well. The time of methadone provision was increased – sites open at 7.30am and close at 4pm and on weekends physicians work longer hours. Attitude of drug treatment specialists changed noticeably, as I said, they responded to our wishes and opened the second methadone treatment site.

- You were talking about the lack of free places paid by the state. As I understand it, in Latvia OST is funded by the state, and for us, in Ukraine, this question remains open as the Global Fund soon will stop supporting our OST programs...  And one more question. How is the situation with take home medications?

- There were times for the Baltic States, when we switched to public funding, Guidelines were developed (recommendations, instructions - auth.) for drug users and OST patients. And we were able to demand the provision of the take home drugs, waiving the guidelines in front of all drug treatment specialists. Of course, take home drugs are provided to the patients whose life is stable, for example, there are no violations and the patient is officially employed. At first things went tight. Very few patients received take home drugs, and even they - with a creak. However now there are practically no problems. Maybe drug experts realized something? In any case, drug treatment specialists in Riga are great. Also people can always turn to me as the leader of the "Doors" or to another member of the group – if we can, we will help. Methadone treatment is free. In syrup form. However, for subutex and suboxone one needs to receive prescription for two weeks. Monthly cost is about ... 200 euros.

-  And what about "stuff"? What is happening on the Latvian drug scene?

- Before 1995 the situation was as everywhere (in the post NIS space - Ed.) – Poppy, ephedrine, etc. Then more heroin became available, drug users began to make less hanka. And so until 2003, - all as always: poppy, heroin, ephedrine, weed, etc. everything little by little. But good quality. Then the quality was getting worse and worse. Now we have almost all drugs present. This year Spices were banned - finally! Now we have criminal responsibility for spice, the same as for other drugs. Yes, growing poppy was banned at the request of the EU. And in 2010 "Hydra" (anhydride - auth.) completely disappeared also at the request of Europe. Only opioid dependent people are rare, and OST is in fact precisely for such people. People who use drugs are generally – poli-drug users, and they are more susceptible to breakdowns. What else? Problems in the OST, I believe, are the same everywhere - alcohol, pills, amphetamines. Those who are socialized - do not use other stuff, because we do not want to lose privileges. Freedom (receiving the take home medication - Ed.), you know, is more valuable than drug dependence.

- Ok let's get back to our victories ... I immediately liked the title of your project "Methadone to combat the dirt roads!". Why so? In general terms, tell our readers about the essence of your project initiatives.

- The first objective of the project was to find out why opiate drug users do not want to become OST patients. In the survey we found that the most frequently cited reason not to enroll in methadone program (hereinafter - MP) is the physical inaccessibility of MP, remoteness of treatment program sites, reluctance to be on the drug treatment registry, and privacy non-compliance concerns.

Another objective was the need to find out why MT clients do not or cannot withdraw from the program, that is, why they do not want to give up their addiction. Here opinions of addiction treatment specialists and MP patients differ. On the one hand, doctors believe that OST is a therapeutic program, and at the same time, they say, it is the way to improve the quality of life, because addiction is a chronic, incurable but treatable disease ... However, MP patients themselves do not regard the participation of medical personnel as a secondary factor, and to completely get rid of drug dependence they rely more on themselves and their loved ones.

You know one of the main reasons why people do not want to join the program - I would say - is a bad reputation of these programs. The image is spoiled by the patients themselves. According to our data, about 20-30% of patients use, drink, swallow different pills, etc. And there is a banal setting, a kind of a common stereotype that supposedly MP "is for life, zombies, the withdrawal is worse than heroin." Of course, we teach to correctly perceive the progrm, the main thing is the desire to return to the normal life, to socialize. Again - a comparison with diabetes .When you take your medicine and just do not add anything. You begin to work. This is especially true for PLHIV and pregnant women.

Then, there is another moment. In small towns, drug treatment specialists do not want to mess with it because of the mercantile considerations. For doctors MP is too much trouble, a lot of responsibility and too little value of all manipulations. Here, too, a lot needs to be changed. For example, the issue of prescription of methadone can increase the interest of doctors.

Well, what do you think about this? And add a few words about the project, ok?

- More help is needed from the social services so that they were interested in helping OST patients. Then all with whom we talked believed that the choice they made was absolutely right, and the program for them was the only way to reconcile their dependence with the "normal" life.

And the project itself ... I will dwell only on the main points. Speaking in bureaucratic language, we have carried out three in-depth interviews and two focus groups with clients of the methadone program in which all the participants answered the same questions, specially designed by EHRN experts. Also, within the project, we conducted a survey of more than 100 opiate users on the reasons that prevent them to enter the MP. As a result of these activities and on the basis of the responses received, we have created a booklet for PUDs "Methadone. Perhaps this is your chance! ", which summarizes the history of OST, its positive aspects, as well as information about who and why should become a participant of the program. Also in our booklet one can learn how and where to start treatment how much money will be needed for this treatment. In addition, we interviewed reputable drug treatment specialists. We assembled very important quantitative statistics on OST clientele in 2012 and 2013 respectively, which now allows for more accurate comparative studies.

- And I have one question for everyone I talk to. About difficulties. What barriers did you encounter during the implementation of the project (and whether it was possible to overcome them)? Usually all our difficulties associated either with doctors or medical officials, or with police. What do you have?

- Materials of the project and an invitation to a presentation and discussion of the project results were sent to all interested stakeholders including the Ministry of Health (MoH), the National Health Service (NHS), the Center for Disease Prevention and Control, the social services of the city, health inspection, non-governmental organizations in HIV / AIDS, the Riga Centre of Psychiatry and Addiction and relevant departments. Unfortunately, the Ministry of Health did not even respond to the invitation. Other services delegated their representatives.

- And what conclusion did you and your guests reach as a result of this discussion?

 - Let me read out from the meeting proceedings. 

"It is necessary to change the paradigm of MP positioning among people who use opiates: instead of a treatment program - a program to improve the quality of life! It is necessary to improve the availability of MT: further decentralization and longer working days. It is necessary to improve the availability of information for MP clients and for people who use opiates and are not MP clients. The information should be in plain language. It is necessary to pay more attention to the potential of communities and to develop a methodology consultation "peer to peer". What do you think? Fine?




Specially for EHRN.

Via Skype Kiev-Riga

October-November 2015



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