drug treatment systems in russian hospitals and prisons: inefficient and lacking in evidence

Drug Treatment Systems in Russian Hospitals and

Prisons: Inefficient and lacking in evidence

Prof. Vladimir Mendelevich, MD, PhD

Kazan State Medical UniversityRussian Federation

Belgrade, 2 June 2015

IDHDP supports drug policies based on the health of individuals and society.

- Protect society and the individual from drug-related death and disease

- “ Health of people first “ - Improve access to essential medicines - Expand access to evidence based treatment

“It is difficult to understand Russia by mind”poet F.Tutchev (XIX sentury)

SwedenSweden

ThailandThailand

SwitzerlandSwitzerland

RussiaRussia

USAUSA NetherlandsNetherlands

ChinaChina

IranIran

UkraineUkraine

AustraliaAustraliaCanadaCanada

EUEU

IndiaIndia

Repressive

Drug policy strategies and drug treatment paradigm

Balance Liberal

EPAAM (2013)

- compulsory treatment

- involuntary registration of drug addicts

- ignoring of drug addicts rights to treatment (ban on OST)

Repressive strategy in drug addition treatment

- heroin-assisted treatment

- safe injection sites

- marijuanna medical use

Liberal strategy in drug addition treatment

- availability of all form of treatment (opioid antagonists, agonists) - availability of care in different places (home, hospital, prison…)

- availability of integrative care (including treatment of co-morbidity pathology)

- supporting of drug addicts rights to treatment

Balance in drug treatment strategy

Balance in drug policy

Global commission on drug policy (2014)

Pathway to drug policy reform

Global commission on drug policy (2014)

- About 2,5 million people use narcotic drugs

- 532 895 are officially registered as dependent on drugs

(345 015 – IDU’s)

- 82,4% of them are dependent on opiates

- More than 30 000 overdoses deaths in a year (the level of overdoses deaths in Russia are higher in 15 times than in EU)

- 907 607 officially registered HIVcases, 67% of patients IDU's. More than 54 000 new cases HIV in 2013

- Effectiveness of drug-free treatment – about 10% one year remission

Contemporary situation in Russian addiction medicine

Legislative drug policy initiatives in RussiaSince 2006

It has been offered to return the practice of the compulsory treatment

2008-2009Introduction of obligatory testing for taking drugs for all students

2010-2012The offer on introduction criminal penalty to the use of drugs

and quasi-coersive (alternative) treatmentThe offer on prohibition of any discussion on agonist opioid treatment

2013The offer on register all drug addicts in police (finish of medical secrecy)

2014Rehabilitation of drug addicts is coordinated not by Ministry of Health, but by

Federal Drug Control Services

2015The offer to forbid images of drugs in mass media and the Internet, a ban on

information of medical use of drugs.

Attitude towards compulsory treatment in Russia

39,6

24,2 26

36,840,1

48,554

31,6

0

10

20

30

40

50

60

all doctors IDU's relatives

agree disagree

V.Mendelevich (2006)

The attitude to the OST (public opinion)

29,5

42,8

27,7

yes no yes-no

V.Mendelevich (2006)

Key Key pointspoints of Russian addiction medicine of Russian addiction medicine

Drug addict is not considered as a patient de facto

The main problems:

The spreaded of procedures of narcological registrationProsecutor General of the Russian Federation has set up all-Russian database of persons who are registered in clinics with diagnoses of

"alcoholism" and "drug addiction." (27 April 2013)

The problem of realization of the principle of “Informed Consent”

Non-observance of patients confidentiality

Using non-evidence based therapies

The ban on opioid substitution therapy

HR programmes in Eastern Europe vs Russia (IHRA, 2014)

HIV among IDU's:new cases in Europe and in Russia

(WHO, 2009; Russian Federal AIDS Center, 2014)

Western Europe – 3,9%

Central Europe - 8%

Eastern Europe – 39,4%

Russian Federation – 57,3%

90th today

Russian narcology: Moralistic and clerical paradigm

The great influence of Orthodox Church

Effective methods for treatment of opioid addiction (attitudes of Russian drug treatment specialists) %

V.Mendelevich, 2006

-23%

+9%

+30%

-11%

Indicators of efficiency of the drug addiction treatment in Russia

19

E. Koshkina, 2013

Treatment standards

The standards of treatment of opioid dependence in Russia are fundamentally different from those

accepted worldwide

Attitudes towards patient's confidentiality in addiction medicine

russians foreign0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

35%

63%

56%

24%

9% 13%

can't saycontrapro

P < 0,01

V.Mendelevich, 2011

Attitudes towards compulsory treatment

russians foreign0

10

20

30

40

50

60

70

80

63%

28%29%

72%

8%

0%

procontracan't say

P < 0,001

V.Mendelevich, 2011

russians foreign0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

22%

9%

41%

11%

38%

80%

contraprocan't say

P < 0,01

Attitudes towards sterilization of mentally ill women

V.Mendelevich, 2011

Support of OST

Support of euthanasiaSupport of position that there will be prohibited

placebo-controlled trails

Opposition to compulsory treatment Support of HR (ENSP)

Support of position that HIV+ patient are not guilty

of his status

Support of position that drug addiction is brain disease

Analysis of system providing drug treatment to convicted persons (methodology)

To make the analysis of the situation with the system providing drug treatment to convicted persons the following data sources were used: - reports of FPS (Federal Penitentiary Service) of the Russian Federation, - materials of the Research Institute of FPS, - articles published in scientific journals, - press conferences of the heads of FPS, - data from interviews with employees of the medical centers of FPS.

Number of prisoners in prisons in the Russian Federation

About 681 000 persons

(Federal Penitentiary Service, 2013)

The crimes connected with drugs – more than 250 000

persons or more than 30% of prisoners

(Federal Drug Control Services, 2013)

Contemporary situation in Russian prisons

In 2012, 124 955 people served sentences for crimes related to drug trafficking.

In 2011 year 15,237 crimes were committed while the felon was intoxicated, an increase of 32.3% from the level in 2010.

Level of narcotic drugs seized in correctional colonies for adults annually

seized (in grams)

2011 - 78 8892010 - 76 324 2009 - 59 864 2008 - 59 968 2007 - 52 9532006 - 36 722 2005 - 22 111

Contemporary situation in prison(IDU, alcoholism)

People with mental disorders account for more than 18 % of persons in custody. In 2012 there were more than 141,000 people with mental and substance abuse disorders in correctional facilities, of whom 62,700 had mental disorders, 56,400 were injecting drug users and 22, 600 patients with alcoholism.

E. Stepanova, 2012

Contemporary situation in prisons (HIV)

In pretrial detention centers of FPS of Russia about 8,000 HIV-infected persons enter every year. Since 2000 year the number of HIV-infected people in correctional institutions increased 3.7 times. In 2012 FPS facilities contained more than 55, 000 people (this is 10% of the total number of HIV-infected patients registered in the Russian Federation and 9% of the total number of persons held in correctional facilities). More than 90% of HIV-infected people are injecting drug users. About 10,000 HIV-infected patients receive antiretroviral therapy, each year the number of patients receiving this therapy increase by 1-1.5 thousand people.

S. Baryshev, 2013

Contemporary situation in prisons(HIV + TB)

 In 2012, there were more than 5, 000 patients with comorbidity HIV + tuberculosis in prisons (9.9% of HIV-infected patients in penal institutions). Morbidity and mortality from tuberculosis in correctional facilities Russia over the past 10 years has decreased by 2 times, the number of tuberculosis cases has decreased by almost 2.5 times (from 80,000 to 33,000). The percentage of new cases of tuberculosis in prisons is about 12% of the total number of patients registered on the territory of the Russian Federation.

S. Baryshev, 2013

Contemporary situation(medical care of prisoners)

In accordance with the concept of development of correctional institutions until 2020 (Decree of the Russian Federation dated October 14, 2010 № 1772 - p) medical care of prisoners and defendants provide 131 different profile hospitals, 59 medical correctional facilities for the patients with tuberculosis, 9 medical correctional institutions for drug addicts, medical units or health centers in each institution.

Contemporary situation:specialists

Currently working in FPS there is a total 622 specialist in the field of psychiatry and addiction medicine, which is about 3 times less than the actual need.

Quasi-compulsory treatment (QCT) (alternative to imprisonment)

- Quasi-compulsory treatments are more likely to work because the

offenders are given a choice- Low costs which enable a higher

efficiency - Convincing results

Quasi-compulsory (alternative) treatmentin Russia (since 2012)

70 patients on QCT in Russia in 2012

The main question:Drug treatment standards and principles

Opioid agonists and antagonists vs antipsychotics and psychosocial rehabilitaion

“It is difficult to understand Russia by mind”poet F.Tutchev (XIX sentury)

Drug Treatment Systems in Russian Hospitals and

Prisons: Inefficient and lacking in evidence

Prof. Vladimir Mendelevich, MD, PhD

Kazan State Medical UniversityRussian Federation

Belgrade, 2 June 2015