Last week, President-elect Donald Trump told reporters he considers any friendship with Russia an “asset,” and his fondness for the country — and, in particular, Russian President Vladimir Putin — is well-known.
But the two countries have very different approaches to opioid addiction. Russia bans methadone and buprenorphine treatment, and Putin closed all opioid treatment programs (OTPs) in Crimea after annexation, and Trump does not always listen to science. So we spent the past several weeks trying to find out what, if any, influence Russia and Putin could have on Trump’s thinking on treatment for opioid addiction.
“Substitution therapy is against Russian law, just as it was in the United States between the 1920s and the late 1960s,” said George E. Woody, M.D., the University of Pennsylvania researcher on substance use who worked on the Russian Vivitrol study. He had been in a meeting in Moscow two months before we spoke to him in December, and said he saw no indication that the law would be changed.
Although there is a legal restriction against providing opioids to individuals who are opioid-dependent in Russia, buprenorphine can be prescribed for pain management for cancer patients, said Thomas Kresina, senior public health advisor in the Division of Pharmacologic Therapies of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA), who helps provide technical assistance to countries receiving PEPFAR (President's Emergency Plan for AIDS Relief) support related to substance abuse treatment and HIV. We talked to him instead of Kevin Mulvey, who is SAMHSA’s person in Kiev, and who was waiting to get approval from the embassy in Ukraine to speak to us. “I’m not clear if methadone itself is illegal in the Russian Federation, or if it could be used like buprenorphine in pain management, but all prescribers know it is illegal,” said Kresina. “Methadone is so stigmatized in the Russian medical community that I doubt anyone would use methadone for pain management.” As an aside, Kresina noted there is street methadone in Russia that is trafficked illegally there.
In fact, Russia never adopted agonist treatment, but the government does fund more than 25,000 inpatient beds for detoxification and treatment, Woody told ADAW. “These are free and have no apparent restrictions on length of stay or readmissions,” he said, noting that this is many more free beds than exist in the United States. “The problem is the high relapse rate after they leave, unless they are started on extended-release naltrexone, which is not widely available due to its cost.” Detoxification beds are widely available throughout the country, he said. Availability of extended-release naltrexone "is mostly confined to programs in Moscow and a few other places that have funds to purchase it."
The last needle exchange in Moscow
“Why is there no methadone and buprenorphine in Russia, and why so much booze?” asked Anya Sarang, director of the Andrey Rylkov Foundation for Health and Social Justice, a grassroots organization for HIV and overdose prevention and the only group offering free needle exchanges in Moscow. “During the Soviet times there was a big opposition to the West and Western ideas, and the Russian narcologists were really against substitution treatment,” said Sarang, whom we reached via Skype in Amsterdam last month. There was some discussion of methadone in the 1990s, but no proposals that would allow for a clinical trial, she said. When Putin came to power in 2000, the ideology didn’t change. “There is no light at the end of the tunnel that Russia will change,” she said. However, there are some harm-reduction programs, first instituted in 1997–1998, involving needle exchanges and referral to testing for HIV, which is a very big problem in Russia. But by 2009 and 2010, the harm-reduction programs started getting clamped down on, and last year the Andrey Rylkov Foundation was labeled a “foreign agent” by the Russian government.
The Russian government never supported harm reduction financially, but before 2009, at least there was no open opposition, said Sarang. And there was initially some promise with government funding for HIV prevention. Asked why, she said “it’s the same reason why the programs weren’t funded in the first place — ideology and the conservative stance of the government.” And here’s the darker side: Officials don’t say it in Russia, but the common understanding is that the policy of the health ministry is to imprison injecting drug users, said Sarang. “People die of AIDS; we have a huge HIV epidemic and a rise of AIDS deaths,” she said. “We have no rehabilitation, and in prison, many people have HIV already, many get tuberculosis, and many die of AIDS.” In Russia, most people with HIV are drug users, she said. “We have to send some clients to Ukraine,” she said. “There’s no way for them to survive in Russia, but in Ukraine, they can get a combination of treatments.”
There is methadone in Ukraine, except in Crimea, which is no longer part of Ukraine but rather part of the Russian Federation since annexation. “The federal drug control service of Russia came and said all methadone programs would be shut down in Crimea,” said Sarang. “There were some attempts at negotiation with UNAIDS [Joint United Nations Programme on HIV/AIDS], but this was unsuccessful.” For a few months, as programs were shut down and patients didn’t receive help, there were deaths — 800, said Sarang. But propaganda kept this from the West. “The U.N. Special Envoy on HIV in Eastern Europe received an official note from the Minister of Health that this is all lies and that actually people used to die even before methadone was closed,” said Sarang. “There was a diplomatic scandal, and after that, all access to data has been shut down. There was no official kind of investigation around these deaths.”
‘Badly managed’ health system
People on the ground in Russia know that “the public health system is very badly managed,” said Sarang. “There is no area in public health where people don’t complain.” But all of the power is in Putin’s central administration, she said. Local authorities are afraid of being punished by the health department, she said. “Unless you are an activist organization like ours, you don’t do it,” she said. “The local administration says, ‘Yes, yes, I understand it is bad, we have an HIV epidemic, but we cannot do harm-reduction programs here.’”
Her group does outreach every night, usually near pharmacies where people buy the eyedrops to dilute heroin with, said Sarang. “We see maybe 10 to 30 people a night, give them syringes, condoms, health information, rapid testing for HIV, counseling and legal aid,” she said. Her work is currently funded by the Global Fund to Fight AIDS, Tuberculosis, and Malaria, but taking foreign funding puts the group at financial risk. “We are the last advocacy and, to be honest, quite loud organization,” she said.
AATOD and ASAM
Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD), is more concerned about who is going to head the Office of National Drug Control Policy (ONDCP) than about any connection between Russia and Trump. “If it’s a person who takes a dim view of medication-assisted treatment, that would be troublesome,” he told ADAW last month. “I can’t imagine that Trump would take any particular position to diminish OTPs, unless he has an adviser like a Giuliani type.” (Rudolph Giuliani, originally thought to be a contender for attorney general, tried to shut down OTPs in New York City when he was mayor.)
Could Trump shut down OTPs? “No, he can’t,” said Parrino. “You can’t shut down OTPs, and you can’t require patients to go on Vivitrol.”
Parrino said he couldn’t even imagine that someone would issue a directive to “de-operationalize OTPs or require them to change medication.” Ultimately, he asked, why do it? “It would be too insane,” he said, “even if Trump doesn’t understand the science.”
However, Parrino does think the Trump administration would be interested in eliminating the regulation limiting the number of patients a physician can treat with buprenorphine.
For the American Society of Addiction Medicine (ASAM), lifting the patient cap is indeed a hopeful sign of a Trump administration.
And Vivitrol is likely to be favored by many in the United States who do not like agonists, having the same biases that are seen in Russia.
Indeed, Vivitrol, first approved in the United States to treat alcohol use disorders, was tested in Russia as a treatment for opioid use disorders. As Daniel Wolfe of the Open Society Foundations pointed out in The Lancet six years ago, Russia was one of the few places in the world where it would have been ethical to conduct a randomized controlled trial with Vivitrol and not include a comparison to the two medications proven to be effective for opioid use disorders (see ADAW, May 9, 2011). It would not have been ethical to give patients Vivitrol compared to nothing in a place where medications that work were available. To this day, that fact has created questions in the treatment community about the real effectiveness of Vivitrol. The criminal justice community, which has a bias against agonist medications, does approve of Vivitrol.
And while Vivitrol meets the ideological needs of the criminal justice system, some policymakers in the United States, and the Russian government, it’s expensive, doesn’t work unless people keep getting the shots and has questionable effects on craving (see ADAW, March 7, 2016).
The global view
While politics shouldn’t guide science, policymakers have their own ideas. And, unfortunately, they often consult themselves instead of scientists when it comes to addiction, say medical officials. “Often policymakers are unaware of or ignorant about addiction,” said Gregory Bunt, M.D., president of the International Society of Addiction Medicine, the global counterpart of ASAM. “HIV prevalence has more than quadrupled and the opioid epidemic is raging out of control in Russia,” said Bunt, who is a clinical assistant professor in the Department of Psychiatry at the New York University School of Medicine. He noted that ignorance among policymakers is not limited to Russia. “It’s also true in the United States,” he said.
Incarceration is not treatment, and both the United States and Russia have a long way to go on that, although access to evidence-based treatment is much more accessible in the United States, said Bunt. “We need to increase access to treatment,” he said.
At the United Nations conference last spring (see ADAW, April 25, 2016), it was understood that treatment must be a priority, said Bunt. Vladimir Poznyak, M.D., Ph.D., the head of substance abuse management for the World Health Organization, has laid out a manual for the U.S. State Department that clarifies that addiction is a treatable disease. “The problem we identified is that the amount of resources devoted to interdiction, prosecution and corrections far surpasses the amount of resources devoted to treatment,” said Bunt. “The problem can’t be solved by the criminal justice system only. But treatment providers understand that under various governments, they have to work within the system. That’s true in the United States and it’s true in Russia.”
So who supports the regime in Russia that is leading to an increase in HIV, AIDS and addiction? “I talk to my circle of people and they say there is 99 percent support of Putin in Russia, but I don’t know anybody who supports Putin in Russia,” said Sarang. “Maybe somebody is happy, but we just don’t know these people.”
It’s too soon to say what a Trump presidency will mean for methadone and buprenorphine, but the anti-agonist Russian model has proven disastrous for that country in terms of addiction and HIV/AIDS.