Harm reduction programs need more flexibility to work properly in Eastern Europe

Restrictive policies that can sometimes prevent people from keeping their jobs could be compromising the effectiveness of Global Fund-supported opioid substitution therapy programs across Eastern Europe and Central Asia, civil society representatives from around the region told Aidspan.

Without improvements to the quality and effectiveness of these programs, they risk driving away the very people who are most in need of the services -- and could undermine the sustainability of these programs once ownership transitions to national governments.

"We want to start talking about OST program challenges, which are not only coverage and finances that are mainly discussed by the donors and NGOs, but also the effectiveness and quality of these programs,” said Andrey Yarovoi, board member for Association of Substitution Treatment Advocates of Ukraine (ASTAU). They consider the fact that OST programs are still pilot, vertical programs that have yet to be integrated into the national health service one of the biggest impediments to their success.

Most doctors who work with people who inject drugs consider OST to be the same drug with different packaging, whereas drug users see it as medical treatment. This disconnect means that program participants are not often treated as patients, and are discriminated against by medical professionals.

Regionally, similar problems with OST therapy have been identified: those enrolled are restricted in their movements due to the need to check in daily to receive their dosage. This means they have a hard time getting or staying in jobs, due to the rigors of being part of the program.

"The overarching problem is that methadone (and buprenorphine where it is available), despite being medicines, are delivered in a framework that prioritizes patient control.  While Western European countries (as well as Australia and the US) all provide stable patients with take home doses, these are unavailable for methadone patients," said Daniel Wolfe, the director of the international harm reduction development program for Open Society Foundations. "Rigid requirements keep patients "locked" to clinics, and unable  to enjoy the social participation that we say we want to return to them (travelling for family functions, taking a few days off, etc), and understandably mistrustful of systems that seem more concerned with control than with care."

Stigma against so-called narcomen is also pervasive; stereotypes about the untrustworthiness of drug users means that even those who are trying to kick their habits by enrolling in OST are viewed suspiciously, and the OST centers are a visible manifestation of that suspicion.

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