Estonia is a country hit hard by the opioid overdose epidemic. People struggling with overdoses in other countries can learn a lot from the Estonian example about what works and what does not work in preventing deaths and suffering. We interviewed Mart Kalvet, an activist representing LUNEST, the Estonian organisation of people who use drugs.

Drugreporter: Tallinn is often called the overdose capital of Europe. Why do so many people in Estonia die of overdose?

Mart Kalvet: People in Estonia, especially in Tallinn, surrounding areas, and in the Ida-Viru County, where the concentration of Russian-speaking people and/or people without citizenship is greater, die of overdoses at a greater rate because they use street opioids, often in combination with other substances – both legal, like alcohol and prescription medicines (clonazepam, diphenhydramine, etc.), as well as illegal, like amphetamines. Most of the people who die of overdoses are injecting drug users. The primary cause of death is almost always listed as fentanyls, because fentanyls are pretty much the only street opioids available in Estonia. There is no one clear explanation as to why that is. The “original” fentanyl — 50 to 100 times more potent than morphine — had made occasional appearances on the market before the start of the current overdose epidemic, but didn’t catch on as the main drug of choice of opioid users before the year 2002. The combination of a long drought in Afghanistan, the post-9/11 US military action in the region, and scrupulous work by Estonian anti-narcotics agencies may have been seminal in crashing the heroin market and facilitating the emergence of suppliers of synthetic black market opioids in Estonia, but these factors don’t really explain why heroin never returned to Estonia, and why there’s no fentanyl problem to speak of (yet!) in the surrounding countries.

Although exact numbers of users of illicit drugs – especially injecting opioid users – have never been known, it is estimated that the population using injectable drugs in Estonia was almost halved after 2002 — if you were an opioid user at that time, you either quit heroin, because it was no longer available, or switched to fentanyl. A lot of the fentanyl users I’ve talked to claim that for them, heroin (which actually tries to make a reappearance on the market now and then, but has thus far failed to make a lasting comeback) has the same effect as injecting clear water. Toxicologists claim that, for fentanyl users, achieving the desired effect takes four or more times more heroin than for an average heroin user, which might mean that the opioid users here couldn’t afford to substitute fentanyls for heroin even if they wanted to.

Another aspect that probably affects the overdose rate is the fact that fentanyl has actually not been widely available in the Estonian black market for some time. Successful busts of great amounts of regular fentanyl by the police in the 2000s made it possible for trimethylfentanyl to emerge as the market leader. In recent years, a similar pattern has repeated — despite the recent blanket ban on all possible fentanyl-type drugs and their precursors, novel fentanyl analogues like furanylfentanyl, acrylfentanyl, carfentanil, ocfentanil etc. appeared on the wider marker… but not before the drug police had managed to infiltrate and take down a large network of trimethylfentanyl suppliers. There appears to be a disconcerting correlation between successful police action and spikes in overdose deaths. Correlation, of course, does not imply causation, and the amounts confiscated represent only a tiny percentage of the amount of drugs consumed daily in the country, but since similar trends are evident everywhere where attempts to solve the problems around the black market of drugs with brute force have been made, the unwanted consequences of enforcement of drug laws should not be overlooked.

I must stress that this is not the official position of Estonian state bodies. The police claim that the correlation is spurious, as according to their sources, the novel analogues had appeared even before the crackdowns. A coordinator of substitution therapy at a methadone centre who’s been active in the field of addiction treatment and harm reduction since the 1990s, told me that every time, before newer, more potent and deadlier drugs appeared on the Estonian market, there would be massive dumping campaigns conducted by organised crime groups who were giving away the new analogues for free for a couple of weeks, until their clientele had been properly hooked. Inquiries among former and active injecting drug users do not confirm such accounts — no-one I know has ever heard of drugs being given away for free — but as far as I know, the question of why these specific drugs have overtaken the market in these specific periods of time in Estonia, or why overdoses spike in the same years that police confiscate record amounts, has never been properly studied. Until that happens, hearsay, speculation, and anecdotal evidence are all we have to rely on.

What harm reduction measures are accessible for drug users to prevent overdoses?

We have harm reduction centres that distribute clean needles and syringes, as well as other gear, but the quality of their work is not uniform, and a lower level of quality appears to be in direct correlation with the overall attitudes of the personnel of these centres towards their clients — people don’t want to go to exchange needles or get methadone from a facility where they’re treated like human garbage. Until now, there have been no mechanisms in place for clients to express either their dissatisfaction with the services, or proposals for making them more efficient.

The official position of the coordinators of Estonia’s methadone program — as well as pretty much everyone involved with the field of drug policy in an official capacity — is that all interventions have to be evidence-based. Unfortunately, there’s no evidence of the level of efficacy of methadone-based substitution treatment for users of fentanyl and fentanyl analogues. That’s understandable, as Estonia is the only place in the world where fentanyls are the drug of choice for the overwhelming majority of street opioid users. Alas, the methadone program’s international evidence base rests on treating only heroin addiction. That may be the reason why a significant percentage of people receiving methadone also inject additionally — and are sometimes kicked out of the programs when caught. Most of the methadone patients for whom the therapy appears to be giving the best results seem to be people who started using opioids in the 1990s or early 2000s, when fentanyls were not yet the dominant opioids on the market, i.e. people who started their opioid use with poppy extract or heroin. The official bodies have noticed this, and we’ve been told by several official sources that a plan to expand the substitution treatment program with state-funded buprenorphine is currently being considered, so hopefully things will be changing in a better direction.

Naloxone is available in Estonia at five harm reduction centres in Tallinn and the Ida-Viru County. People who want to get it — drug users, their family members, and people with an otherwise heightened probability of witnessing an overdose — have to take a half-hour training course. Unfortunately, awareness of the effects of naloxone, its role in reviving overdose victims, and its availability among injecting drug users is relatively low. I have heard several accounts from people who were stopped and frisked, and after finding a naloxone kit on their person, taken to the police station for medical tests, and later fined and/or arrested. The police don’t hang around needle exchange facilities anymore, trying to arrest clients, but carrying a syringe, either used or clean, on your person is still considered probable cause for drug-testing by the police, which undermines the efforts of harm reduction workers. We’ve recently been told by representatives of the state police and border guard board that such practices are now heavily discouraged, which, if true, would definitely be an important step in the right direction… but I’d like to see that written into law as well.

Repressive drug policies fuel overdoses in Estonia – An interview with Mart Kalvet

Release - the UK’s centre of expertise on drugs and drugs law - has been providing free and confidential specialist advice to the public, and campaigning for the reform of drug policy, for 50 years. To celebrate our 50th anniversary, we hosted the Museum of Drug Policy in London from November 3rd-5th.

The Museum’s exhibitions depicted the human suffering caused by the drug war, and highlighted how drug policy and drugs policing intersect with issues of social control, especially in relation to class and race. Alongside the Museum, we also celebrated the work that Release has undertaken over the past five decades. For more information on Release's history, click through our interactive timeline.

The Museum of Drug Policy is a pop-up arts and cultural hub featuring live programming and art from around the world that highlight how drug policies impact and shape our communities. It provides a powerful, emotional experience that illustrates the harms caused by current prohibitionist drug policies and advocates for new approaches rooted in dignity, health, and human rights. The Museum transports audiences across the globe, pushing visitors to think and act outside the box through interactive installations, powerful documentary photos, multimedia displays and more.

The Museum of Drug Policy is supported by the Open Society Foundations and was first launched in New York City in April 2016.

Release teamed up with partner organisations to design and present numerous panels and interactive workshops alongside the exhibition. Partners included drug policy and harm reduction organisations, sex workers organisations, LGBTI groups, and movements working on issues of race.

Release’s 50th anniversary: the Museum of Drug Policy

I’m headed to Kenya next week for work I told my friends – Really? The response. Does Kenya have a particular drug problem? Why are you headed there? My reply, where doesn’t have a drug problem? Here’s my story of why I went and what I discovered on my Kenyan drug policy reform campaign journey.

We were off to launch Anyone’s Child Kenya – the latest extension to our successful campaign. Anyone’s Child is a growing network of families whose lives have been destroyed by the drug war, who speak out for the need to legalise and regulate drugs.

I first met Lugard, the Kenyan founder, a few years ago at our office in Bristol. He visited as an African fellow on a training programme organised by Release. I’d mentioned the Anyone’s Child campaign and how we were trying to tell the real stories of the drug war, and he’d told me the story of his friend who had died from police brutality because of her involvement with drugs. He mentioned how much it had impacted him and driven him in his work (read more here).

We then invited him to attend the 2016 United Nations General Assembly meeting in New York, where we held a rally of families from across the world who wanted to change the debate around drugs. The mood was clearly both rallying and inspiring, and Lugard returned home and felt compelled to set up his own extension of the Anyone’s Child campaign in Kenya – an African first!

Kenya and the universal power of story

Aidsfonds and the International HIV/AIDS Alliance are pleased to announce this Call for Proposals on regional activities for the PITCH program in Southern Africa: To strengthen lobby and advocacy aimed at expanding HIV combination prevention in Southern Africa.

With this call, PITCH aims to support civil society organizations and networks to effectively engage in and shape the regional HIV prevention agenda in Southern Africa1. Organizations that meet the definitions and criteria set by this call for proposals are invited to apply for a grant to support the proposed activities for three years (2018-2020).
The deadline for submission of proposals is 8 January 2018. Proposals should be submitted through the online application form. For more information please contact grants@aidsfonds.nl

Call for proposals: Lobby and advocacy to expand HIV combination prevention in Southern Africa

HEALING THE HARMS OF RACIALIZED DRUG POLICIES: A NEW NORTH STAR STATEMENT

2017 has been a challenging year for many of us in the harm reduction movement. Between a dramatic shift in the political landscape and the increased toll of the overdose epidemic, we are challenged to rethink how we do our work, and to what ends. What is the work of harm reduction in this moment, and how do we imagine harm reduction futures?

Harm Reduction Coalition remains deeply committed to our mission and the harm reduction principles that have grounded our efforts and inspired our staff for over two decades. But we also recognize that we’re at a critical juncture in our movement, demanding that we take a more strategic and intersectional approach to securing transformational change.

We realized that we were seeking a new way to orient us, a clear vision to guide us moving forward: a North Star.

On behalf of the Harm Reduction Coalition, we are thrilled to present our new North Star statement to you—our beloved community.

Harm Reduction Coalition creates spaces for dialogue and action that help heal the harms caused by racialized drug policies.

Our North Star statement has three key implications for Harm Reduction Coalition:

 compels us to play new roles as conveners, facilitators, coalition builders, and mobilizers that move us beyond our traditional core activities in training, capacity building, and policy. Second, the call to 

 makes explicit a broader vision of harm reduction that extends beyond prevention and risk reduction, pushing us towards reparative strategies to address trauma, social divisions, injustices and inequities, and health. Third, we name 

 as a nexus of damage and threat to all people who use drugs.

Harm Reduction Coalition's North Star statement

The implementation of the Kremlin’s law on “undesirable organisations” is reaching farcical proportions.

“We actually thought we had ‘mopped up’ our website and got rid of those ‘undesirable’ hyperlinks, but we missed one,” Anya Sarang told me, chuckling ruefully. Sarang is the head of the Andrei Rylkov Foundation, a prominent Russian group working to advance responsible drug policy. This week, a court in Moscow fined the group 50,000 rubles (US$862) for involvement with an “undesirable organisation”. The charges stem from a 2011 hyperlink on the group’s website to a publication on the website of the Open Society Foundations (OSF), which Russian authorities banned two years ago.

Russia’s 2015 law on “undesirable organisations,” authorizes the prosecutor general’s office to ban from the country any foreign or international organization that it alleges undermines the country’s security, defense, or constitutional order. OSF is one of the 11 organisations, mainly American donor institutions and capacity building groups, already blacklisted.

Once designated “undesirable,” an organisation can no longer carry out any activities in Russia. Moreover, the law provides for administrative and criminal penalties for Russian groups and citizens that cooperate with “undesirables” — administrative fines for the first two violations, and then a maximum six-year prison sentence.

A hyperlink to absurdity: How Russia's law on “undesirable organisations” impacts civil society

The Ugandan Ministry of Health has made a breakthrough decision to pilot needle and syringe programmes (NSP), led by the Uganda Harm Reduction Network (UHRN) and Community Health Alliance Uganda (CHAU).

The NSP programme will reach 250 people who inject drugs in four districts (Kampala, Mbarara, Mbale and Gulu). The pilot is being implemented by UHRN and will run until December 2018 as part of the Ugandan Global Fund programme, with a vision to scale up to more sites in Uganda.

The landmark decision was confirmed by the Ministry of Health in September. It is the result of soft and evidence-based advocacy led by Alliance Linking Organisation CHAU in partnership with UHRN, a drug user-led network that delivers peer-to-peer HIV and harm reduction services.

Wamala Twaibu, Executive Director at URHN, said: “For the past six years our strategy has been to use soft skills advocacy, targeting high level and influential persons in the Ministry of Health, and within internal affairs and law enforcement circles, to accept the concept of harm reduction in Uganda.

“With support from the Alliance’s PITCH programme [Partnership to Inspire, Transform and Connect the HIV response], we have been able to amplify the voices of people who inject drugs more effectively. Through their shared testimonies we have been able to voice out the need for needle and syringe programmes and established collaborative working relationships.

"People who use drugs have been supported to participate and organise at a grassroots level, and take part in high-level meetings and decision-making fora at district, national and global level. This has enabled us to finally secure Ministry of Health buy-in for the implementation of the needle and syringe programme in the country.”

Thumbnail: International HIV/AIDS Alliance

Breakthrough as Uganda announces harm reduction pilot

A facility in Lethbridge will become North America’s first supervised inhalation site when it opens early next year amid a drug death epidemic that has devastated families across the province.

ARCHES is the only organization or health board in the country, so far, to be granted approval by Health Canada for a site that will permit all four modes of drug consumption: injection, oral, intranasal and inhalation.

The approval allows drug users to smoke drugs like methamphetamine (crystal meth), as well as crack cocaine and heroin in specially ventilated rooms at the site.

“People are not just dying from injecting — they’re dying from snorting, taking pills orally and they’re also dying from smoking,” says ARCHES executive director Stacey Bourque.

“So it was really important of us to address all four modes of consumption, not just injection.”

Canada's first supervised inhalation site for meth, crack cocaine users to open in Lethbridge

Coca, opium poppy, and cannabis are cultivated by millions of people, mostly in the Global South. International law requires governments to uproot and destroy all cultivation of these crops not related to accepted medical and scientific use, but drug crop production still proves to be a promising livelihood for many rural populations. Efforts to replace cultivation with other activities have been mostly unsuccessful, and the current prohibitionist approach comes at an extremely high cost, including endangerment of small-holder farmers as they are pursued by police and military forces.

Drug crop production, poverty, and development - Video

How cultural attitudes, the political environment, and donor expectations shape harm reduction – and how they can divert it from its original mission as a movement.

We have been producing movies about drug policies since 2007. Through all these years, we have been traveling a lot across the world, visiting harm reduction sites and interviewing hundreds of harm reduction activists, professionals, and decision makers in various countries.

It is easy to make premature judgments about harm reduction in a country. I always have my own preconception about it before actually traveling there, based on articles and reports I have read. Most of the time, I have to admit that the reality is much more complex than my expectations. My experience tells me that sometimes countries labelled as retrograde in terms of drug policy and harm reduction can amaze you with vivid, vibrant local harm reduction scenes. And countries praised for their progressive drug policies can equally disappoint you with their rigid, medicalised systems.

Sometimes you learn the most cutting edge lessons about harm reduction and human rights among the people living in disadvantaged countries. A mistake often made is that the experience of these people is underestimated, and only success stories are highlighted and celebrated by reports from international organisations. Exchanging experiences and knowledge among decision makers and harm reduction professionals working in similar, difficult environments is often as useful as presenting best practices from Western countries. Lack of measurable success in changing policies is not necessarily a sign of the failure of advocacy efforts.

Thumbnail: Drug Reporter / Harm Reduction Coalition

Harm reduction beyond numbers

Dr Luiz Loures, Deputy Executive Director of UNAIDS, fully admits that he is not an expert on human rights.

He is a medical doctor with decades of experience, but he has seen how ignorance and stigma can prevent access to health care.

Loures was a doctor early on in the HIV epidemic. During that time, Loures dealt first hand with the stigma and fear associated with HIV. He often would work 18-hour shifts in hospital, as his colleagues were too afraid to assist with his HIV patients. And patients were diagnosed late, if at all, because of the fear of being labelled with the disease.

Things have changed in the 30 years since the HIV crisis first began, he said, but discrimination against people with HIV because of stereotypes and other stigma are still a barrier to accessing health care.

“What I see in terms of stigma …it seems like we are stuck in the 80s,” Loures said. “And it is clear today that this stigma is killing (people), and bringing a new crisis (in health care) to us.”

For the community that Brun Gonzalez works with, stigma and stereotypes are often underpinned by laws. Gonzalez is the chair of the International Network of People who Use Drugs and drug users are a group pilloried because of the criminalization of drugs and their associated negative impacts.

“Then people who are health service providers have this frame work where they see people who use drugs as delinquents, who strain their services, are linked to organized crimes, who are twisted, altered, sick people who have no morals, no values what so ever,” Gonzalez said. “So they don’t want to engage them, they don’t want to provide services, they don’t want to use needles around them to give them medicines.”

But there is hope and that hope comes through human rights, said UN High Commissioner for Human Rights Zeid Ra’ad Al Hussein. Substantial evidence shows that in every context, health policies and programmes based on human rights deliver better health outcomes, he said in his address to the Forum.

“We know what needs doing and why it should be done, and we know too that it makes financial sense,” he said. “Epidemics and pandemics demonstrate that everyone's health is interconnected – not only in the literal sense of contagion, but also in terms of economic and social impact. An extensive and nuanced body of international and national law elaborates the scope of the right to health. Access to health-care of quality is not a privilege for the wealthy few, but a universal right – and where this right is prioritised, everyone benefits.”

Thumbnail: Support Don't Punish Campaign, Global Day of Action 2017 (Russia)

Experts: Stereotypes and fear continue to block access to health care for some

Hepatitis C is not only a health issue. Without addressing the social exclusion of Roma people, repressive drug policies and the attacks against NGOs, there is no way to end the epidemic. Lessons learnt from Hungary.

The Rights Reporter Foundation organised a panel discussion on hepatitis C in Budapest on the 2nd of October. We invited activists and professionals, including Dr. Tamás Tóth, a hepatologist from the Semmelweiss University, Tamás Berecky, an activist working for the European AIDS Treatment Group, Virág Kováts, a social worker from the harm reduction NGO Altalap and Nagyné Antal Tünde from VIMOR, the Hungarian Association of Chronic Liver Patients. Before the discussion we screened our movie “The Time Is Now to Eliminate Hepatitis C” (embedded in the end of the article), produced in cooperation with the Correlation Network, filmed at the Hepatitis Community Forum in Amsterdam. The movie provided an international context by highlighting the momentum to end the epidemic with the help of highly effective new medications (read our earlier article!).

The discussion aimed to identify the major barriers and challenges to ending hepatitis C in Hungary, where the epidemic has been rapidly growing among injecting drug users due to an increase in stimulant injection and the lack of adequate access to harm reduction services. Between 2011 and 2014, the prevalence of hepatitis C among injecting drug users increased from 24% to almost 50%. In the same period, the two largest needle and syringe programs were shut down and the number of distributed needles and syringes decreased from approximately 650,000 needles per year to just 150,000 needles per year. We can state in no uncertain terms that the anti-harm reduction and anti-NGO turn of the Hungarian government resulted in thousands of new hepatitis infections.

With the advent of direct-acting antivirals (DAAs) we can now massively reduce the harm from hepatitis C. Interferon-free DAA regimes are short, highly tolerable, and simple to deliver, with cure rates of over 90%. However, the price of these drugs is still prohibitively expensive and this prevents large groups of society from accessing them. The Hungarian government did not challenge the patent of the drug. They created a central registry for hepatitis C patients (HepReg), with a risk score calculator of patients registered with hepatitis C. There are long waiting lists and only those with severe liver damage can access the new treatment. Tamas Berecky, who was living with hepatitis C himself, described his own struggle through the maze of this system (read his brilliant article here!). He realised that he wouldn’t be able to receive DAAs before his liver became damaged so he explored the alternatives. He found out about drug tourism in India, where cheap, generic hepatitis drugs are available. Some Hungarian hepatologists even teamed up with tourist agencies to organise the patients’ trips to the country. However, he also realised that it is legal to order this medication online. He took the pills and was cured. Now he is helping his peers to do the same.

Testing sounds easy – but for marginalised people, such as the majority of people who use drugs and are living with the virus, it is not feasible. First of all, they do not even have access to voluntary testing and counselling services. They could previously be reached through harm reduction services, but these services are now in decline and often lack the resources to buy HCV testing kits. Even if they access tests, they will not receive treatment. Dr. Tamás Tóth estimated the total number of people living with hepatitis C at 50,000, from these 20,000 were tested positive, 10,000 received some kind of treatment and 6,000 were cured. Although the vast majority of people who test positive for hepatitis C are now people use drugs, only a small proportion of them get treatment. They often don’t have health insurance, a registered place of residence, and/or identity cards. They are invisible to the public health system.

THOSE WHO ARE MOST IN NEED ARE NOT TESTED

According to all international recommendations governments must focus resources on the testing of those who are the most vulnerable, that is, people who inject drugs. However, the Hungarian government is ignoring these recommendations. It allocated 6 billion Forints on combating hepatitis C. This is a fair amount, according to Dr. Tamás Tóth it would be enough to treat each and every person living with hepatitis C in two years, so long as it is spent on testing and treating the most vulnerable. But the government spends this money on testing campaigns among less vulnerable groups, such as health workers. Last year for example, each and every worker of the Honvéd Hospital were tested for HCV. From 2000 health workers only 2 tested positive, and one of those had known his status for years. This is a frustrating example of how much-needed resources are wasted in vain. And according to Dr. Tóth the government is planning to spend 600 million HUF next year to test health professionals. At the same time harm reduction NGOs cannot even afford to buy HCV tests, not to mention needles and syringes. And even if they do, their work is often blocked by overzealous police officers.

Dr. Tamás Tóth reported about the HCV testing project they conducted with the support of a pharmaceutical company in the correctional system. They tested prisoners in the Állampuszta Penitentiary Institution, where they found that the prevalence of hepatitis C was ten times higher than among the general population. Those who tested positive were mostly young Roma males, living in deep poverty and with prior experiences of drug injection. Those people who were treated whilst in prison were cured, but those who left without treatment were lost from the treatment system. There is no connection to community services who could have channeled these people to the public health care system. He emphasised that hepatologiss are only part of the equation. It is not possible to scale up access to HCV treatment without investing in social support and harm reduction programs.

One of the recurring themes of the discussion was the lack of coordination among different actors; connections are missing between social and health care. Only a few hepatologists treat drug users, one of whom is Dr. Olga Szabó at the addiction treatment department of the Nyírő Gyula Hospital. The Ministry of Human Resources fails to show leadership. The government created a climate of fear and suspicion towards NGOs, which are scapegoated and demonised. Government institutions that were responsible for making public policies, such as the National Centre of Epidemiology, the National Drug Prevention Institute or the National Drug Focal Point were abolished and/or merged with the Ministry, where they work under direct political control.

TO END HEPATITIS C IS NOT ONLY A PUBLIC HEALTH ISSUE

To end the hepatitis C epidemic is not only a public health challenge, it cannot be abstracted from the wider social and political context. Most new infections are registered among marginalised groups in society, especially people who inject drugs. Official reports rarely emphasise that in our region, Central and South-Eastern Europe, most of these people are Roma, who suffer from multiple forms of systemic discrimination and social exclusion. The same governments that allocate resources on fighting hepatitis C are reluctant to address underlying social inequalities, poverty, homelessness, unemployment, and segregation as the root causes of both growing drug problems and infections. What is more, local and national governments often promote policies based on discrimination, criminalisation, and segregation. Austerity measures cutting back health and social care budgets, and punitive criminal policies targeting poor communities, are major barriers to accessing hepatitis C prevention and treatment services. Governments must use their legal powers to force the prices of drugs lower. There is a need for more synergy among public health professionals, harm reduction organisations, law enforcement officials, and organisations supporting marginalised Roma people. The most affected communities should be involved in designing services and making policies. International organisations must support the building of these coalitions that can promote alternative policies based on integration and inclusion.

News