To: Ombudsman of the Russian Federation Mr. Vladimir Lukin

Reaction of the Global Initiative on Psychiatry to the letter “Response to inquiry from Russian Federation Ombudsman about substitution therapy” addressed to Mr. Vladimir Lukin, Russian Federation Ombudsman, signed by the President of the Independent Psychiatric Association of Russia Y.S. Savenko

Global Initiative on Psychiatry (GIP) is an international not-for-profit organization with the mission to promote humane, ethical, and effective mental health care throughout the world and to support a global network of individuals and organizations to develop, advocate for, and carry out the necessary reforms. GIP, as an organization promoting comprehensive, integrated drug treatment, rehabilitation and care that is adapted to individual needs expresses deep concern about the repressive nature of drug treatment services in the Russian Federation.

There are around 1.6 million people injecting opiates in Russian Federation1 resulting in one of the highest HIV epidemics in the world, while opioid substitution treatment (OST) remains to be illegal. The State does not provide services to stem drug dependency and related health complications2. The standards of drug treatment still include antipsychotic drugs known for their use in political repressions of Soviet dissidents3 and therefore are contradictory to the international drug treatment standards. Moreover, GIP expresses the concern over the limited availability of any drug treatment and repressive nature of such treatment, as methods of drug treatment available from non-state actors include flogging therapy, handcuffing to beds for long periods, and hypnotherapies4.

GIP, as an organization uniting professionals working in psychiatry and collecting information on most efficient approaches to mental health, would like to draw the attention to the scientific evidence of OST effectiveness.

Substitution maintenance therapy is one of the most effective types of pharmacological therapy of opioid dependence. There is consistent evidence from numerous controlled trials, large longitudinal studies and program evaluations, that substitution maintenance treatment
for opioid dependence is associated with generally substantial reductions in illicit opioid use, criminal activity, deaths due to overdose, and behaviors with a high risk of HIV transmission5.

Currently, OST is used in 70 countries worldwide, with approximately 1.2 million people in treatment6. OST programs were introduced into the majority of European countries, which led to a significant drop in HIV transmission rates among people who inject drugs, and prevented the HIV epidemic from spreading to the general population.

OST is also cost effective method of opioid addiction treatment having wide political support. It is endorsed by the Joint United Nations Program on HIV/AIDS, the United Nations Office on Drugs and Crime and the World Health Organization7, moreover, methadone and buprenorphine are on World Health Organization Essential Medicines List8. It is also important to note that the prescription for OST and administration of opioid agonists to persons with opioid dependence is in line with the 1961 and 1971 Conventions on narcotic drugs and psychotropic substances.

Promoting modern evidence-based services in psychiatry and highlighting importance of fundamental human rights principles and ethical approaches, GIP recognizes the urgent need to endorse access to OST and other relevant harm reduction programs in Russia. In the light of the emergency brought about by the HIV and AIDS epidemic, which hit injecting drug users the hardest, it seems that Russia should review its current legislation and undertake at least pilot methadone/buprenorphine projects to deliver drug treatment alternatives immediately.

Medical professionals and psychiatrists particularly, should be among those who actively advocate OST, but, to achieve that, they also should have reliable sources of information and education about it. The international community of drug addiction treatment specialists could become an important source of information and education for Russian health care specialists. Therefore, the necessary steps should be made by the Russian Government in order to shift the drug treatment from repressive approaches to scientific and evidence based methods. GIP recommends to:

- Remove legal barriers and initiate the widespread provision of opioid substitution therapy with the use of methadone and buprenorphine, in accordance with the guidance from the World Health Organization (WHO);
- Provide trainings and facilitate study tours for Russian health care specialists should be developed at all levels to improve the degree of knowledge and understanding of the importance of OST and other relevant harm reduction programmes.

Respectfully yours,

Chief Executive

Dr. Robert van Voren

1 UNODC (2009). World Drug Report of the UNODC, 2009.

2 Human Rights Watch (2007). Rehabilitation Required. Russia’s Human Rights Obligation to Provide Evidencebased Drug Dependence Treatment, Human Rights Watch.

3 Faraone, S (1982) Psychiatry and political repression in the Soviet Union. American Psychologist , Volume 37 (10): 1105.

4 Interfax article "Defense of Bychkov", with comments by the Director of the Federal Drug Control Service of the RF, V.P. Ivanov.; References to sites of private clinics, city without drugs

5 See for example: WHO/UNODC/UNAIDS (2004). Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention : position paper / World Health Organization, United Nations Office on Drugs and Crime, UNAIDS, World Health Organization, United Nations Office on Drugs and Crime, Joint United Nations Programme on HIV/AIDS, 2004; Amato L, Davoli M, A Perucci C, Ferri M, Faggiano F, P Mattick R. An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. J Subst Abuse Treat 2005 Jun;28(4): 321-9; Connock M., Juarez-Garcia A., Jowett S., Frew E., Liu, Taylor R.J., Fry-Smith A, Day E., Lintzeris N., Roberts T., Burls A., Taylor R.S. Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. Health Technology Assessment 2007; Vol 11: number 9.

6 Mathers B, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick R, et al. HIV prevention, treatment and care for people who inject drugs: A systematic review of global, regional and national coverage. The Lancet 2010. DOI:10.1016/S0140-6736(10)60232-2.

7 WHO (2009). Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. Geneva: World Health Organization; 2009.

8 16th WHO Model List of Essential Medicines. Geneva: World Health Organization; 2009. Available at: