«It is crucial for me that people stop seeing those who are drug-addicted as animals»

How do you translate into Russian "Support. Don’t punish"? Long live the World Revolution?

Moscow outskirts. A park. Under the bridge on the bank of the Moscow River, a couple dozen people have a picnic: someone is doing barbecue, someone puts feet in the water, someone chops vegetables or just has a rest. Shortly before that, these people played football. It would seem a very trivial way to spend your leisure time on the air in a residential area. The only difference is that the participants of the picnic are the wards of the Andrey Rylkov Foundation for the Promotion of Health and Social Justice (Russian abbreviation is FAR). A group relaxing under the bridge consists of several employees of the foundation, while the rest are drug users.

The foundation staff organize BBQs with quizes from time to time to rally people, create a community and bring useful information not in the form of lectures, but in the form of entertainment, with dialogue and involvement of the addicts themselves.

Before the start of the quiz, human rights activists read the opening speech: “Today we did not just play football. In 1987, the UN decided to declare June 26 the day of fight against drugs. But everything turned out not as we wanted: they started fighting not with drugs, but with people who use them. But we have gathered to support the International Support. Don't punish" campaign. We want to say that drug users should not be purged or imprisoned. We are for support, not for punishment.”

The quiz starts. The first question: How do you translate in Russian  "Support. Don’t punish"? Response options: “calm down, no panic,” “support, not punishment,” “long live the World Revolution.”

Interrupting each other they begin shouting “support, not punishment.” Prizes have been announced. Those who give the biggest number of correct answers will be presented with T-shirts. The number of respondents is increasing, then they agree to answer raising a hand, like at school. The one who raises a hand first answers. Immediately several leaders stand out.

Questions gradually become more difficult and flow into discussions:

- Guys, what do you feel about this campaign? - ask foundation staff.

- Drug addicts should be treated, they should not be imprisoned, an environment should be created for them. - responds someone in a crowd.

- He [a drug user] must not be imprisoned, he should be provided with a job, acquainted with people, shown that life exists without drugs...

- Life is possible even with drugs.

- I am 30 years old, if I do not stop now, I will never stop.

- You don’t have to give up drugs, you can live with them. Many drug users have families, work, and so on.

- They want something risky, to see if they will be caught or not. I have friends who go shoplifting just for extreme.

Then they discuss Article 228 of the Criminal Code (illegal production, sale or transfer of narcotic substances - editor's note), the weight of substances for which they get different terms of imprisonment, drugs decriminalization:

- Those who have friends condemned for a small weight, please, raise your hands, ask volunteers. Everyone raises hands.

- Should a person be put in prison for 0.5 [gram] of heroin?

- No.

- Yes.

- I suppose they (law enforcement officers - editor's note) should check for [the amount of] substances, sometimes, you take the "five" - and then ...

- Punishment does not help a person at all. I have never seen so much drugs as in prison.

- I was imprisoned for 0.01 [gram].

After asking some more questions, they end up with a discussion of substitution therapy and awarding. They give presents to everyone: flashlights, household trifles, souvenirs, T-shirts with a Support. Don’t punish" print.

Hat and accordion

Andrey Rylkov Foundation for the Promotion of Health and Social Justice has been engaged in harm reduction and HIV preventive treatment among drug users since 2009. The foundation does several activities: direct field outreach twice or three times per day on foot or by bus. In addition, social support (it is also called case management): they help to go to the hospital (someone is afraid to go alone), to get rehabilitation, etc. The foundation conducts a “primary motivational conversation” to find out what a person wants, what he/she needs, what he/she can do him-/herself, and when assistance is needed.

Another type of assistance is the work of street lawyers to “identify cases of rights violations”, to motivate people to defend their rights: write complaints, applications, etc. “If a lawyer sits in an office in the foundation building, nobody will come to see him at all. A special feature of drug users is that it is difficult for them to get ready, come across town, calculate the time so that they take all the documents and, moreover, to be high (took the drug - editor's note),” explains Maxim Malyshev, a street social work coordinator.

The Foundation also works with the children of drug users. Several times a year foundation staff take them together with their parents to theatres, museums, planetarium, etc. Their goal is not just to take children somewhere, but to make a platform for interaction between children and addicted parents. For the New Year they collect money for gifts and deliver them to the apartments. In addition, employees of the foundation are creating now a comic book with the participants.

“At some point, we realized that parents could not tell children about their illness, addiction," continues the coordinator. "This is a very tabooed topic that brings shame and guilt to life. Parents hide [illness], grandmothers lie that their mom has overslept, and dad went on a business trip for two years. At the same time, parents love their children, but because of illness they have some peculiarities: in the morning they are blazed, therefore they cannot do anything, then they need to get a drug... Another reason that lies in the life of children is an additional factor that can lead to children also becoming addicted. Children feel a lie. We thought that we would find parents who might like to clarify the relationships with the children and tell the child that "despite the fact that we are addicted and have a lot of problems, we love you". Therefore, we decided to describe everything in an accessible form of a comic book. We conducted 15 interviews with mothers and fathers, and based on their stories we are creating a comic book. ”

It is believed that it is difficult to make a full-fledged community of drug users due to the nature of the illness. The Andrei Rylkov Foundation does not want to agree with this and makes every effort to socialize and establish communication among addicted. They arrange the exchange of goods, bookcrossing, publish a newspaper "Hat and accordion", where they tell about the rights and health of users, stories written by the wards themselves. They gather in the foundation and play board games on Saturdays. They watch films every two weeks.

Today and tomorrow have months between them

The foundation is created and focused on solving people's problems here and now. Andrei Rylkov Foundation staff focus their work on the request of people gradually, step by step. Today we gave a syringe and tested a ward, tomorrow we will cure a trophic ulcer. And the day after tomorrow it might be possible to sit down and talk, to offer help if a person is tired of using drugs and he or she wants to recover. Sometimes the distance between "today" and "the day after tomorrow" can stretch for months.

Drug users are one of the most stigmatized people of society. It is difficult to imagine who is treated worse and more dismissively. However, according to Maxim Malyshev, the stigma cannot be eliminated. It is beneficial to society, because there is always someone to blame for the problem and call “scapegoats”: “Society is organized in such a way that people tend to blame some groups for something," he develops his thought. “But it is crucial that discriminated people should not be imprisoned, imposed unnecessary cases in the police, or refused treatment.” The same policemen and doctors should not like these people, maybe they have their own experience of injury, but it is impossible to turn it into discrimination.”

He does not offer any unusual ways to combat discrimination: sharing information about drug addiction as a disease, decriminalization of drugs, and even legalization. According to his logic, if there was legalization, the government would control the drug trafficking, not criminal gangs, substances would be cheaper, sick people would get prescription access to them, and now, instead of legally buying, for example, marijuana, it is necessary to plunge into drug business and also feed and support it. And if you get caught by the police, it is also possible to be imprisoned for a long time.

Oleg Zykov, Director of the National Institute of Narcological Health, supports the idea of decriminalization of drugs: “It seems to me that this way is historically predestined. It is proved by a significant evidentiary database. The most interesting here is the analysis of the changes that have occurred since 2001 in a particular country – Portugal. And, in this sense, the collection of materials of the Global Commission on Drug Policy is absolutely invaluable.”

“If you read the 2020 strategy to counter the HIV epidemic, there are only two approaches to drug users. The first approach is inclusive testing, the second one is rehabilitation. I have nothing against it. These things are good, but they only work if done at the same time”, says Malyshev.

He explains that it is difficult for people to go to state AIDS centres, to choose and come to the exact appointed time, because they are on drugs. Another point is that nobody prescribes an adequate scheme for drug users. There are often strong side effects. People begin to take pills and feel worse. As a result, they give up. In addition, there is no enough therapy for everyone.   

Nowadays, there is no other organization in Moscow except Andrei Rylkov Foundation that would deal with grassroot street social work. And as a result, no one enters a very closed group of drug users, where relationships are built step by step for a long time. The government does not allocate money to outreach.

The chief narcologist at the Ministry of Public Health and the Director of the Moscow Scientific Practical Centre (MSPC) of Narcology, Evgeniy Brune, explained to Novaya Gazeta why there was no outreach work in the national drug policy: “The medical community in general is sceptical about the distribution of syringes on the streets, because, by handing out these materials we pay attention to the sphere of those citizens who have never thought about it. It turns into drug promotion."

Oleg Zykov, Director of the Institute for Drug Abuse National Health, “absolutely agrees” with the effectiveness of “harm reduction” programs. He refers to the options expressed in the report of the International Narcotics Control Board (INCB). He notes that the International Board is "one of the bodies in the UN system that is responsible for the topic under discussion and traditionally expresses the most conservative position." There is a chapter in the report that contains “interventions to reduce the negative effects of drug use”, all of these measures were “scientifically evaluated” and “give the greatest effect when applied in an integrated way”. Among them: needle and syringe exchange programs; opioid substitution therapy and other drug treatment; HIV testing and counseling; antiretroviral therapy; preventive treatment, diagnostics and treatment of sexually transmitted infections; distribution of condoms; targeted information, education and communication; preventive treatment, vaccination, diagnostics and treatment of viral hepatitis; and preventive treatment, diagnostics and treatment of tuberculosis.

Substitution therapy

In the West substitution therapy is considered to be one of the most significant and effective ways to combat the spread of HIV infection. This approach involves the use of a narcotic substance that has less narcotic potential as a legal alternative to heroin and other highly addictive drugs. Now two substances have been approved for substitution therapy: methadone and buprenorphine.

However, it is not applied in Russia. The national health care system does not recognize it, in particular, the chief narcologist of the Ministry of Health opposes substitution therapy. Here is what he wrote in his column in the newspaper “Izvestia”: “I would like to dwell separately on the topic of “substitution therapy”, in discussions about which many spears were broken as well as during the work on the strategy. The ban on methadone therapy in Russia is absolutely justified. Such a “treatment” does not contribute to the formation of the patient’s desire to abandon the use of psychoactive substances.”

Brune also added: “With regard to the role of “substitution therapy” as a factor in the response to the HIV epidemic (and especially in this context it is promoted today), the failure of these programs in Ukraine clearly indicates not only the lack of effectiveness of such technologies as a method of HIV preventive treatment, but its inapplicability in Eastern Europe in general.

Oleg Zykov, Director of the Institute of Drug Abuse National Health, on the contrary, advocates the introduction of substitution therapy, and also explains that it is not used in Russia because of: “The repressive mental background prevailing in a society where only one way can easily be perceived as a solution to any problem - “finding and punishing a culprit”. And also because of the ignorance and poor knowledge of decision-makers in this sphere.”

In response to a question why there is no substitution treatment in Russia, Malyshev lists three most common theories, not insisting on any of them.

The first reason, according to many, is that the organizers of drug business are afraid of loosing their income because of the availability and legality of drugs. Maxim himself believes that it is not true. The second is the fear of security officials involved in the fight against drugs, that someone will still steal methadone for substitution therapy and sell it on the black market, and drug users will almost attack pharmacies. The third is that this is all nonsense, which does not work, because the goverenment will not have to treat addicted people, but to give them the drug. And this is strange logic, because it is impossible to cure people with such therapy, it is created for a totally  different purpose.

Malyshev recalls that in the early 2010s, the Minister of Health mentioned in an interview that the effectiveness of harm reduction and substitution therapy was not proven, and therefore there was nothing to talk about: “At that time we were surprised by these words, because there were a lot of research, recommendations of the WHO and others. We thought that maybe the Minister did not understand something or did not know where to read about it or how to use Google. We decided to do the work for her and her assistants. We went to the UNAIDS, collected a stack of studies, books, printed a lot of literature, collected a huge package and took it to the Ministry of Health. We wrote that we had read her interview, and the thought had crossed our mind in that you did not understand a little about the subject ”.

Grassroot social work

Residential area in the outskirts of Moscow. Not far from the metro there is a grey panel block of apartments next to a park. There are shops and a pawnshop on its ground floor. There is a place where drug users congregate.

Two foundation employees stand in front of them with large tourist backpacks. They distribute syringes of different sizes from "insulins" (1 ml volume) to "tens" (10 ml volume), Naloxone, condoms, clean water for injections, alcohol wipes, dressing materials, bandages, patches, nets for fixing bandages, pregnancy tests. They conduct rapid HIV tests through saliva, as well as give out self-test kits.

Due to the poor quality of drugs and the large number of injections, a great number of wards have complications and trophic ulcers. Therefore, they also distribute Levomekol ointment for purulent wounds and Troxevasin for veins. Since many people no longer have veins due to regular drug use, they have to prick in the groin. As a result blood clots are formed in the veins of the legs, and blood circulation is disordered.

Drug users do not always immediately trust employees of Andrey Rylkov Foundation. “Newcomers” view volunteers with apprehension. They check if those are connected with the police and if they are going to close the pharmacy (the police often conduct so-called “pharmacy manhunts” in the hope of arresting drug users with a “dose” when they buy syringes in pharmacies before the upcoming injection). But getting used to them, drug users also talk themselves about such pharmacies, thereby increase the coverage of those in need. On average, from 7 to 40 people pass through outreaches per shift.

Elena Remneva, an employee of the foundation, has been already working for the foundation for four years. She came there because her close person had drug addiction and HIV infection. Firstly, she asked for help, then she was offered to stay in the foundation and help.

“It is my life's work, these are my values," she explains. "I want something to change in our country, something to shift in this area. Suddenly, Naloxone will become over-the-counter, or, according to the 228 [article] the dose of the substances, for which people are imprisoned, will be increased. I will already know that I have made my contribution. When I work, I tell many ordinary strangers about people with HIV. It is important for me that people start thinking differently, so that they no longer see drug addicts as animals. There are periods when it is easier for me to communicate with drug users, because when they see that we are not connected with either the police or a drug abuse clinic, they become very open, humane.”

Eugene (name has been changed) come to the outreaches, they have known each other for a long time. Evgenyi takes only condoms. He is HIV posistive. He gave up using drugs after prison. Even before prison, he saw the leaflets of the foundation and began to take "accordeons" (syringes - editor's note). When he was imprisoned he asked the foundation for help, they were able to ensure that a doctor came to the man and prescribed therapy.

“I came here (when he got out of prison - editor's note), got registered. The workload is such that I do not need therapy," he shares his story. "But sometimes I do not have enough sleep, because I work as a delivery boy. If the foundation had not helped, I would have been lost in this prison. There is a barrack for people with disabilities, and they even have [******] (beaten) people with disabilities (Penal colony-3 in the Kursk Region - editor's note). Now I go to them only for condoms. I like to watch films with them. We come and communicate. Guys always warmly welcome.”

Outreaches always work in twos for safety reasons. Now in Moscow, people from the Caucasus actively trap robbery. They wait for drug dealers around pharmacies and rob them of their purchases. They are interested in tropicamide or "lyric drug". According to human rights activists, Caucasians are on these drugs, but they do not prick tropicamide, like the majority of drug users do, but they drip into the nose. According to their logic: if you do not prick, you are not addicted.

Remneva explains that in Russia there is no understanding at all that people can use drugs and live a socialized life at the same time: “In every outreach you hear that a person is tired, he cannot do this anymore. When people use drugs systematically, buzz is not enough for them, but they have myriads of problems. But even if a person decided to give it up, he or shee still has many problems with getting treatment. Everyone feels that in our country you get illnesses, threats of prison sentence, breaking up with your relatives, but not socialization.”

Problems arise literally at every stage. “There are no documents. They could have been lost, could have remained in the department, could have been laid for money. That means you cannot go to the hospital," she continues. "Also, it will not be possible to just go to the hospital if you do not have registration in Moscow. We have a lot of people who are not from Moscow. Many more fear the register of drug addicts, especially women with children, because they will be deprived of parental rights. Plus, people do not want a negative attitude of doctors towards themselves and doubt the effectiveness of treatment. They see that someone was treated, then he got out and started using drugs again. People face obstacles and drop out.”

Ivan (the name has been changed) says that he has not used drugs for almost half a year. He is proud that everything is all right and he has goals. Only when he had severe toothache, he had to prick Ketorol. He could not go to the dentist. He has not got neither documents, nor an insurance document. Now he is trying to save money for a ticket to Rostov.There are relatives whom he is going to live with. Ivan himself is from Moscow, but he cannot live here with his relatives. His younger sister chases him out of the apartment. He says that his relatives poisoned him and put larvae in the food: “I didn’t think that relatives could be so douchey.”

“I gave up drugs. I go to rehabilitation courses, to psychotherapy, I come back from work after 10 days, and my neighbours commemorate me,” he shares his story. "I go upstairs to my flat. There is nothing in my room, no computers and no fishing rods. Nothing except white walls. She threw away my icons, photographs of my dead wife. I tried to live under different, but I have not tried to live soberly yet. Maybe I will like it." Ivan's wife died, he has a 19 year old daughter.

Malyshev agrees that access to rehabilitation and detoxification should be low-threshold. If you want you can go to the hospital. He explains that if a person is not from Moscow, he/she has no opportunity to go to the drug treatment hospitals. If he/she is a Muscovite, he/she needs to go through the bureaucratic chain: get a certificate from a narcologist, a certificate from an AIDS centre, undergo fluorography, and syphilis analysis. Besides you need to stay for 28 days on detox in order to get to rehabilitation.

Malyshev cites his own experience as an example. He has been on the detox five times, and it’s extremely difficult to stay there all 28 days: “The first week you are injected, you lie there like a vegetable, God willing, you can get to the toilet. The second week, the doses of drugs are reduced, sometime after 10 days problems with sleep begin. You hang out in the corridor. You can not watch TV, read, don't know what to do. You are no longer blazed, and you do not know what to do all 28 days. But the standards are like this.”

Another problem is the rehabilitation itself, there are very few state rehabs. As he said, there are only a few in the whole country. The next problem is returning to proper life after rehabilitation and recovery. A person needs some socialization skills, a profession and a job. Often all the skills and knowledge previously acquired are lost as the person has been a drug user for many years. And someone has never had them.

In addition, the percentage of recovering people who are in long-term remission is extremely low: “Within three years after rehabilitation, 80 percent of people will return to drugs. We have to accept it. This disease has its own characteristics.”

Oleg, the foundation ward, comes to the employees not for the first time. He regularly shows new points - pharmacies - where drugs are sold without prescription. Recently he was on rehabilitation, he was "removed" from methadone. The process was difficult. On the 21st day he was kicked out of the hospital, when hospital staff found out that he was HIV-positive: “They packed things and said to wait to be brought out. They took everything away from me. I lay without a blanket, without anything. My son came and took me. It was difficult to go, because recently doctors gave me a strong injection. Next day they didn’t put me in the hospital and didn’t register me. We need to wait for the confirmation of the diagnosis."

Saving a life with prescription

According to the foundation's information there are a lot of drugs in Moscow and they are different. They differ depending on the region: You can find street methadone, salts, amphetamine and methamphetamine, and heroin. In Russia you can hardly find it anywhere apart from Moscow.

The so-called street methadone has a more prolonged effect. You can prick once and feel normal for the whole day. Sometimes you have to take heroin several times a day. Remneva knows users who have access to street methadone. Thus people carry out replacement therapy on their own: fewer pricks, fewer risks. It is possible to work normally.

Drugs are dirty. Sometimes you find fentanyl (another opioid drug - editor's note) instead of heroin. It is more difficult to calculate a necessary dose, so overdose occurs often.

The drug Naloxone rescues from overdose. It blocks opioid receptors in case of overdose. You can not buy it anywhere without prescription or get it. It is distributed only by the employees of the foundation on the streets. This is a tremendous help, saving lives of hundreds of people.

Remneva adds that they give out two ampoules per person. One is not always enough, and people often use it. In addition, if you mix alcohol with opiates, the risk of respiratory arrest increases. If you do not inject Naloxone on time, a person will die.

“We have already wanted for three years it to become over-the-counter,” resented Malyshev. “We have gone through a lot of things. For a year we corresponded with the Ministry of Health, with the Moscow Endocrine Plant, then began to picket both. Now we are at a dead end. The next step is to go to court opposing the Ministry of Health to make a judicial precedent that a medication saving people from overdose is not available to people.”

The chief narcologist of the Ministry of Health does not support Naloskon’s over-the-counter release. “As for me, all medicines should be prescripted, and not only Naloxone,” he said to the same Novaya Gazeta. "A drug user may have possible complications with its injunction. Spreading this drug without prescription is undesirable.”

The head of the Institute for Drug Abuse National Health is confident that Naloxone “must” be sold in pharmacies without prescription.

Last year Andrei Rylkov Foundation saved 423 lives thanks to the distribution of Naloxone. In total, in 2017, Rylkov Foundation has 3,727 wards or, as they call them, participants. The staff conducted 879 consultations, tested 214 people for HIV infection, documented 107 cases of violations of the rights of drug users. 651 participants received legal assistance.