Russia declares “total war” on the country’s drug problem
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4194 (Published 04 July 2011) Cite this as: BMJ 2011;343:d4194All rapid responses
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The Kremlin believes it can force drug users into one of two choices:
prison or enforced treatment (and by treatment they mean detoxification,
as they are opposed to opiate substitution prescribing). (Reference 1).
There is yet a third choice that experience worldwide has reliably
demonstrated that drug users are most likely to make - and that is to
evade capture in the first place, continuing to use drugs, harming
themselves and their communities as they do so, and, importantly,
recruiting new drug users; this is partly because using drugs is
pleasurable, at least in the early days, so one naturally encourages once
friends to join in the party, and partly to fund their own habit - in
effect, drug use is contagious.
As demonstrated ably by the UK's 1998 10-year drug strategy,
recruiting maximum numbers into opiate substitution treatment using a
pragmatic and harm minimisation approach can effectively 'neutralise' this
contagious effect of drug use, and successfully reduce the numbers of new
users entering drug dependence pool. Best estimates show that in the UK,
between 2006-7 and 2008-9, there were statistically significant decreases
estimates of opiate and/or crack cocaine users in the 15-24 and the 25-34
age groups, whilst at the same time, there were increases in the numbers
using the same drugs in older age groups. (Reference 2) What this shows
is that our historical pool of drug users is getting older, only a few are
quitting completely, but at least being on opiate substitution treatment
means they are recruiting less new users into the pool. There is not much
point in trying to empty the bath until you turn the tap off: we have not
turned the tap off completely but at least we have slowed it down. Now we
have the breathing space to work on the longer term addicts and enable
them to engage in a full recovery pathway in the way Michael D'Souza has
illustrated very well, as per the 2008 Government drug strategy
The idealistic, moralistic, and ultimately unrealistic approach of
the Kremlin has not been thought through, and is in effect, a gigantic
experiment with human lives - I predict it will fail. By this I mean that
the numbers of blood borne viruses and other injecting related
complications will rise, the numbers of new users will rise year on year,
crime levels will rise and more and more families will break down as a
result of drug use. In addition to this, I predict the numbers of fatal
overdoses will rise over and above that which is due simply to prevalence,
due to the planned increase in inpatient detoxification which is known to
carry a high risk of subsequent overdose due to relapse in a low-tolerance
state. (reference 3) I hope I am wrong.
Reference 1:BMJ 2011;343:d4194
Reference 2: National and regional estimates of the prevalence of
opiate and/or crack cocaine use 2008-09: a summary of key findings
Gordon Hay, Maria Gannon, Jane Casey:
THe Centre for drug Misuse research,
universiy of Glasgow
Tim Millar: THe national drug evidence Centre, University of Manchester
http://www.nta.nhs.uk/uploads/summaryprevalanceestimates2008-2009.pdf
(Accessed on 15/7/11)
Reference 3 1. Strang J, McCambridge J, Best D et al. Loss of
tolerance and overdose mortality after inpatient opiate detoxification:
follow up study. BMJ, 2003:326: 959-60.
Competing interests: No competing interests
It is understandable that your last correspondent (and it seems the
Russian government) are frightened by the damage that can be caused by
personality damaged individuals. Sadly their proposed solution has already
been found to be not only hugely expensive but actually counterproductive;
punishing semi-suicidal patients merely increases the very stress that
triggers so much of the drug abuse and personality disorder we see.
Using stress lowering medical intervention for treating chaotic substance
abuse is at last being recognized as humanely preferable as well as being
much more cost-effective. However we need better interventions and
research suggests that long term personal assistance to encourage
individuals to socially reintegrate works best. In our contingency
management scheme we provide patients with the opportunity of earning
increasing rewards for caring better both for themselves and others.
Coupled with personal medical care this has been found to help them make
real progress to recovery. To demonstrate this such "recovery" programs
need continuous audit and we would like to offer your readers the
following simple categorisation which we have been using for this purpose;
A. ADRIFT: Doing major self/social damage by INJECTING Class A and/or
other street substances. With possible sub-categories:
Ad; Adrift Using Dirty/ Shared needles
Ax; Adrift Using Clean needles e.g. via needle eXchange
B. BETTER / Semi-stable; NO EVIDENCE OF INJECTING. May be accepting
medical substitutes but still often using street substances on top.
C.CLEAN of Street Drugs: Stable: Randomly tested as Class A street
clean. Stable on variable dose of substitute medication.
D. DETOXING: Undergoing a Home or Clinic Detoxification
E. ESCAPING; Post-Detoxification. Undergoing Rehabilitation/Relapse
Surveillance
F. FREE and reintegrating into Society. With possible sub-categories:
Fj; Free - Job seeking - Off benefit
Ft: Free in Training
Fw; Free - Working (FW)
Fp; Free Parenting in Training (Ft)
Fr; Free Retired
G. GONE AWAY. No longer assessable.
Gdd. Gone Died of Drug use
Gdo. Gone Died of Other cause
Gl. Gone; Left the area
H. HUNG UP No progress on current management
In our general practice during the last 5 years 31 chaotic patients
(of whom 65% were injecting i.e. category A) were started on this
approach. In under a year
90% had stopped injecting i.e. became category (B) since then
87% have become street clean i.e. become category (C) Now
33 % have stopped ALL opiates including Methadone /Subutex i.e. become
category F) of these
35 % are now looking for work (Fj), and 10% are actually working (Fw).
Yours,
Dr Michael D'Souza MD FRCGP FFPHM (CareCreds.org)
Competing interests: I am involved in providing care for Substance abusers. www.carecreds.org
How refreshing to hear that somewhere in this rapidly deteriorating
world, there is the promise of tough action against the scourge of drugs.
We all know the devastating effects that the drug establishment has
on society; it reflects poorly on mankind that so little is being done.
Users are individuals who have been persuaded, either through peer
example or some kind of character underdevelopment, but they are not
suffering from the illness of drug addiction.Those who talk about
addiction being an illness are the ones who profit from this attitude, the
first step into drug dependency is called choice.
Dealers are a different kettle of fish.
And very malodorous fish.
I have long been of the opinion that only drastic, even barbaric measures
will reduce drug addiction and deaths.
However, strict laws in some countries appear to be only a moderate
deterrent (Turkey, Indonesia etc.)hence an effective anti-drug measure
must be introduced with fanfare and with a great, scary and very public
presence.
I suggest we throw all law enforcement resources (which are
considerable and very costly) at catching and locking up the suppliers.
Then, on a regular basis, say every other Sunday, invite the world to
watch what happens to those who do not deserve to be in society. There are
still guillotines around, other methods can also be cost-effective and the
end results would be a society cleansed of those incorrigible criminals.
Any other method is bound to accomplish very little.
However, I shall not hold my breath. The industry has grown so huge
that the negative economic impact of a drug free society cannot be
tolerated.
A little like modern medicine?
Competing interests: No competing interests
It is not a war, it is not even problem solving
The news item described the words really pronounced in Moscow, but
missed the content and the context.
Russia is in a big trouble with misuse of drugs. But it is not that
simple. Russian drug control agency is very ineffective. They prefer to
struggle in the court with the home owners, who got one (literally) wild
poppy seed in their garden and to control drug stores. When we look at
their successes from what they reported, we find out, e.g., that yesterday
they reported as about great success the confiscation of 120 g of grass
and other substances. It is the imitation of the "war" and misuse of state
resources. The major object of their efforts - the drug addicts, who are
pressed and robbed everywhere.
The same with codeine and desomorphine produced from it. The tablets
and syrups containing codeine were sold as prescription only drugs till
2005. Then Ministry of health put the codeine containing drugs on the OTC
drug list. Soon these drugs became the best sellers of the Russian market.
Literally, one combination drug was the second in the list of best sellers
of Russian drugs. The total volume of trade of the codeine containing
drugs is enormous. The company, which sells five different drugs of this type, and profits
hugely from this trade is allegedly connected to the Russian minister of
health's family [http://en.novayagazeta.ru/data/2011/044/01.html;
http://rumafia.com/person.php?id=1418].
This spring, when the media campaign was launched against the liberal trade of codeine containing drugs, health minister Golikova kept the pause and then promised to take these drugs from the OTC list in 12 months.
Usually the "war on drugs" is led by informed government and the "army" of the interested society and medical specialists, who provide the weaponry - the evidence based interventions. The most dramatic is the plan to compulsorily screen all school and university students by blood and urinalysis. The government appointed medical adviser in narcology, E.A. Briun MD,
insisted that he developed the tests which makes possible to detect the
one time consumption of the drug many months before test
[http://www.echo.msk.ru/programs/assembly/754770-echo/].
Only the critique by human rights activists and the evidence based medicine society prevented the speedy introduction of the program. Now it is modified as a voluntary screening. But, of course, it is proposed as voluntary in the presumption, that everybody who rejects testing is
supposedly a drug user. The questions about the false positives and
necessity to test the program efficiency before it is implemented are just
ignored by the Government.
Russian Government succeeds to get the federal law barring the use of
the substitution therapy for drug addicts. More, the idea of substitution
therapy is pictured as a diversion of the perverse West against Russia.
More, the harm reduction programs are closed around the country. Minister
T. Golikova explicitly said that the introduction of the harm reduction
programs is encouraging the drug misused and led to the spread of HIV
in Russia. On 7 July the Speaker of the Russian parliament's low chamber "Duma" B.
Gryzlov at the official meeting said that for drug users the alternative
to a prison term may be enforced treatment
(http://ria.ru/beznarko_news/20110707/398565562.html).
If the war is a lie, crime and corruption, then Russia really is in
the war.
Competing interests: No competing interests