The Soviet doctor and the treatment of drug addiction: "A difficult and most ungracious task"

This paper reviews the development of early Soviet drug treatment approaches by focusing on the struggle for disciplinary power between leading social and mental hygienists and clinical psychiatrists as a defining moment for Soviet drug treatment speciality that became known as "narcology." From this vantage point, I engage in the examination of the rise and fall of various treatment methods and conceptualizations of addiction in Russian metropolitan centres and look at how they were imported (or not) to other Soviet republics. As clinical psychiatrists appeared as undisputed victors from the battle with social and mental hygienists, the entire narcological arsenal was subdued in order to serve the needs of mainstream psychiatry. However, what that 'mainstream' would be, was not entirely clear. When, in 1934, Aleksandr Rapoport insisted on the need for re-working narcological knowledge in line with the Marxist approach, he could only raise questions and recognise that there were almost no "dialectically illuminated scientific data" to address these questions. The maintenance treatment of opiate users, which emerged as the most effective one based on the results of a six-year study published in 1936, was definitely not attuned to the political and ideological environment of the late 1930s. Maintenance was rather considered as a temporary solution, in the absence of radical therapeutic measures to free Soviet society from "narkomania." As the Great Terror swept across the Soviet Union, Stalin's regime achieved its objective of eliminating drug addiction from the surface of public life by driving opiate users deep underground and incarcerating many of them in prisons and the Gulag camps. In the final section, I briefly discuss the changing perceptions of drug use during the World War II and outline subsequent transformations in Soviet responses to the post-war opiate addiction [Additional file 1]

Feasibility of needle and syringe programs in Tajikistan distributing low dead space needles

Background In 2012, the World Health Organization recommended that needle and syringe programs offer their clients low dead space insulin syringes with permanently attached needles. However, in many countries, these syringes are not acceptable to a majority of people who inject drugs. This study assessed the feasibility of working with needle and syringe programs to implement the WHO recommendation using low dead space detachable needles. The study also assessed the acceptability of the needles. Methods Two needle and syringe programs in Tajikistan—one in Kulob and one in Khudjand—received 25,000 low dead space detachable needles each. The programs distributed low dead space detachable needles and a marketing flyer that emphasized the relative advantages of the needles. Each program also enrolled 100 participants, and each participant completed a baseline interview and a 2-month follow-up interview. Results At follow-up, 100% of participants reported trying the low dead space detachable needles, and 96% reported that they liked using the needles. Both needle and syringe programs distributed all their needles within the first 60 days of the project indicating use of the needles, even among clients who did not participate in the study. Conclusions This project demonstrates that it is feasible for needle and syringe programs to offer and promote low dead space needles to their clients. The findings indicate that low dead space needles are acceptable to needle and syringe program clients in these Tajikistan cities. To reduce HIV and hepatitis C virus transmission, needle and syringe programs should offer low dead space needles, low dead space insulin syringes in addition to standard needles, and syringes to their clients

The Opium War at the "Roof of the World": The Administration of Addiction in Soviet Badakhshan

Many Soviet commentators on narcotic drugs in Central Asia have explained the "elimination" of drug addiction in early Soviet Tajikistan in the following ways: in the absence of drug treatment facilities in Tajikistan drug users were treated in neighbouring republics; drug use prevention strategies were successfully implemented through the so-called red teahouses functioning as cultural and sanitary enlightenment clubs. However, red teahouses had entirely failed to address narcotic drug use in early Soviet Tajikistan, and until the late 1930s most of them had operated as ordinary commercial facilities without delivering the "red-coloured" propaganda, "cultural enlightenment" activities, and health education. Furthermore, the actual situation with regard to drug treatment in Tajikistan in the 1920s and 1930s was far more complex and differed dramatically from how it was presented by Soviet physicians, with few Tajik drug users ever receiving treatment both inside and outside the country. This raises a question of vital importance for our understanding of the administration of addiction in Soviet Tajikistan. If the overwhelming majority of drug users were left untreated and if red teahouses did not prevent the consumption of narcotics by the local population, how, in fact, did the Soviet authorities "eliminate" drug addiction in early Soviet Tajikistan? A search for the answer to this question in a wide range of archival documentation and medical records from Tajik psychiatric hospitals reveals a tragic opium war that took place in Soviet Badakhshan and ended with deaths and repressions during Stalin's Great Terror in 1936-1939. It had profound and far-reaching effects in terms of driving opiate users of the Soviet Pamirs deep underground and placing many of them in prisons, so that medical workers could neither see nor hear about them for several subsequent decades

The Opium War at the "Roof of the World": The Administration of Addiction in Soviet Badakhshan

Many Soviet commentators on narcotic drugs in Central Asia have explained the "elimination" of drug addiction in early Soviet Tajikistan in the following ways: in the absence of drug treatment facilities in Tajikistan drug users were treated in neighbouring republics; drug use prevention strategies were successfully implemented through the so-called red teahouses functioning as cultural and sanitary enlightenment clubs. However, red teahouses had entirely failed to address narcotic drug use in early Soviet Tajikistan, and until the late 1930s most of them had operated as ordinary commercial facilities without delivering the "red-coloured" propaganda, "cultural enlightenment" activities, and health education. Furthermore, the actual situation with regard to drug treatment in Tajikistan in the 1920s and 1930s was far more complex and differed dramatically from how it was presented by Soviet physicians, with few Tajik drug users ever receiving treatment both inside and outside the country. This raises a question of vital importance for our understanding of the administration of addiction in Soviet Tajikistan. If the overwhelming majority of drug users were left untreated and if red teahouses did not prevent the consumption of narcotics by the local population, how, in fact, did the Soviet authorities "eliminate" drug addiction in early Soviet Tajikistan? A search for the answer to this question in a wide range of archival documentation and medical records from Tajik psychiatric hospitals reveals a tragic opium war that took place in Soviet Badakhshan and ended with deaths and repressions during Stalin's Great Terror in 1936-1939. It had profound and far-reaching effects in terms of driving opiate users of the Soviet Pamirs deep underground and placing many of them in prisons, so that medical workers could neither see nor hear about them for several subsequent decades

HIV among people who inject drugs in Central and Eastern Europe and Central Asia: a systematic review with implications for policy.

BACKGROUND AND OBJECTIVES: HIV among people who inject drugs (PWID) is a major public health concern in Eastern and Central Europe and Central Asia. HIV transmission in this group is growing and over 27 000 HIV cases were diagnosed among PWID in 2010 alone. The objective of this systematic review was to examine risk factors associated with HIV prevalence among PWID in Central and Eastern Europe and Central Asia and to describe the response to HIV in this population and the policy environments in which they live. DESIGN: A systematic review of peer-reviewed and grey literature addressing HIV prevalence and risk factors for HIV prevalence among PWID and a synthesis of key resources describing the response to HIV in this population. We used a comprehensive search strategy across multiple electronic databases to collect original research papers addressing HIV prevalence and risk factors among PWID since 2005. We summarised the extent of key harm reduction interventions, and using a simple index of 'enabling' environment described the policy environments in which they are implemented. STUDIES REVIEWED: Of the 5644 research papers identified from electronic databases and 40 documents collected from our grey literature search, 70 documents provided unique estimates of HIV and 14 provided multivariate risk factors for HIV among PWID. RESULTS: HIV prevalence varies widely, with generally low or medium (10%) prevalence in Eastern Europe. We found evidence for a number of structural factors associated with HIV including gender, socio-economic position and contact with law enforcement agencies. CONCLUSIONS: The HIV epidemic among PWID in the region is varied, with the greatest burden generally in Eastern Europe. Data suggest that the current response to HIV among PWID is insufficient, and hindered by multiple environmental barriers including restricted access to services and unsupportive policy or social environments

Factors mediating HIV risk among female sex workers in Europe: a systematic review and ecological analysis.

OBJECTIVES: We reviewed the epidemiology of HIV and selected sexually transmitted infections (STIs) among female sex workers (FSWs) in WHO-defined Europe. There were three objectives: (1) to assess the prevalence of HIV and STIs (chlamydia, syphilis and gonorrhoea); (2) to describe structural and individual-level risk factors associated with prevalence and (3) to examine the relationship between structural-level factors and national estimates of HIV prevalence among FSWs. DESIGN: A systematic search of published and unpublished literature measuring HIV/STIs and risk factors among FSWs, identified through electronic databases published since 2005. 'Best' estimates of HIV prevalence were calculated from the systematic review to provide national level estimates of HIV. Associations between HIV prevalence and selected structural-level indicators were assessed using linear regression models. STUDIES REVIEWED: Of the 1993 papers identified in the search, 73 peer-reviewed and grey literature documents were identified as meeting our criteria of which 63 papers provided unique estimates of HIV and STI prevalence and nine reported multivariate risk factors for HIV/STI among FSWs. RESULTS: HIV in Europe remains low among FSWs who do not inject drugs (<1%), but STIs are high, particularly syphilis in the East and gonorrhoea. FSWs experience high levels of violence and structural risk factors associated with HIV, including lack of access to services and working on the street. Linear regression models showed HIV among FSWs to link with injecting drug use and imprisonment. CONCLUSIONS: Findings show that HIV prevention interventions should be nested inside strategies that address the social welfare of sex workers, highlighting in turn the need to target the social determinants of health and inequality, including regarding access to services, experience of violence and migration. Future epidemiological and intervention studies of HIV among vulnerable populations need to better systematically delineate how microenvironmental and macroenvironmental factors combine to increase or reduce HIV/STI risk

Breaking worse: the emergence of krokodil and excessive injuries among people who inject drugs in Eurasia.

BACKGROUND: Krokodil, a homemade injectable opioid, gained its moniker from the excessive harms associated with its use, such as ulcerations, amputations and discolored scale-like skin. While a relatively new phenomenon, krokodil use is prevalent in Russia and the Ukraine, with at least 100,000 and around 20,000 people respectively estimated to have injected the drug in 2011. In this paper we review the existing information on the production and use of krokodil, within the context of the region's recent social history. METHODS: We searched PubMed, Google Advanced Search, Google Scholar, YouTube and the media search engine www.Mool.com for peer reviewed or media reports, grey literature and video reports. Survey data from HIV prevention and treatment NGOs was consulted, as well as regional experts and NGO representatives. FINDINGS: Krokodil production emerged in an atypical homemade drug production and injecting risk environment that predates the fall of communism. Made from codeine, the active ingredient is reportedly desomorphine, but - given the rudimentary 'laboratory' conditions - the solution injected may include various opioid alkaloids as well as high concentrations of processing chemicals, responsible for the localized and systemic injuries reported here. Links between health care and law enforcement, stigma and maltreatment by medical providers are likely to thwart users seeking timely medical help. CONCLUSION: A comprehensive response to the emergence of krokodil and associated harms should focus both on the substance itself and its rudimentary production methods, as well as on its micro and macro risk environments - that of the on-going syndemic of drug injecting, HIV, HCV, TB and STIs in the region and the recent upheaval in local and international heroin supply. The feasibility of harm reduction strategies for people who inject krokodil may depend more on political will than on the practical implementation of interventions. The legal status of opioid substitution treatment in Russia is a point in case