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Campaigners Urge Fresh Start in Tajik War on Drugs

As Tajikistan faces rising numbers of addicts and a related increase in HIV infection, experts say the authorities need to stop persecuting addicts and start offering substitute therapies instead.
By IWPR Central Asia
Campaigners in Tajikistan are calling for the use of new therapies for drug users in the early stages of treatment, to curb the growing problem of addicts who turn to crime as well as the rise in HIV infection.



They say substitute therapies, including the use of heroin substitutes such as methadone, could reduce the overall number of addicts.



Lobbyists for substitute therapy include members of the United Nations-funded National Coordination Committee for the Prevention and Fight against HIV/AIDS, Tuberculosis and Malaria.



They cite the fact that many countries are successfully treating addicts using methadone as a substitute for heroin, enabling patients coming off heroin to avoid withdrawal symptoms.



A synthetic drug, similar in its effects to heroin, methadone is ingested orally, substantially decreasing the risk of users becoming infected with HIV through contaminated needles.



Injecting drug users are highly vulnerable to HIV and most cases of new infection now derive from shared needle use.



More than 60 per cent of the 842 people officially recorded as HIV-positive this year are known to be injecting drug users. The apparent rise in the number of HIV-positive cases in Tajikistan also suggests that the overall number of drug addicts is increasing.



Opponents of replacement therapies, who include some health officials, remain dubious of the benefits of methadone, fearing it could have the opposite effects to those intended.



ADDICTION FIGURES HARD TO GATHER



Tajikistan is one of the main exit routes for Afghan heroin heading north and west to markets in Russia and the rest of Europe. It is believed that around 20 per cent of Afghan heroin production is exported via Central Asia, and the rest through Iran and Pakistan. As heroin retails at relatively low prices in the region, Tajikistan and its neighbours have seen a rise in addiction rates in recent years, along with the associated problems of crime and HIV infection via dirty needles.



Despite efforts to improve interdiction on its southern border, Tajikistan can expect to see rising volumes of heroin used locally as well as transiting its territory, as production in Afghanistan looks set to continue the rapid increase seen in recent years. The United Nations Office on Drugs and Crime believes Afghanistan produced 8.2 tonnes of opium in 2007, up from 6.1 tonnes last year and double the 4.1 tonnes that were produced in 2005.



There is no agreement over the precise scale of drug addiction in Tajikistan owing to the lack of clear, undisputed statistics.



According to the health ministry, there are about 8,000 drug addicts in Tajikistan. But independent bodies insist the number is far larger, putting it at as much as 20,000 in Dushanbe alone.



“According to estimates from the United Nations Office on Drugs and Crime, in Tajikistan today there are 20,000 drug users, of whom 15,000 inject,” said Dr Murtazokul Khidirov, director of an organisation called Rahoi az Nashamandi (Ways Out of Drug Addiction), who has been working on the problem for many years.



“According to our data - and we work inside Dushanbe - there are at least 20,000 injecting drug users here [in the city],” he added.



And while the health ministry insists the numbers of drug addicts is falling, reports from regional anti-drug services suggest the exact opposite.



Jafarkhon Ishaki, from the Sogd regional directorate of the national Drug Control Agency, said at a press conference in late October that since the beginning of 2007, the number of registered drug addicts in this northern region had increased dramatically from 1,015 at the beginning of the year to 1,785 as of October 1.



Dr Khidirov says the huge disparity in statistics can be put down to the fact that many addicts are fearful of making the central authorities aware of their addiction, in case they end up in jail. Addicts are liable to be arrested and charged with a variety of different crimes. Their homes are raided by police and they do not receive much in the way of treatment.



“Our society does not consider drug addiction a disease,” said Dr Khidirov. “Sufferers are castigated, humiliated, accused and put in jail for it.”



Unsurprisingly, it is a minority of addicts that seeks medical help from the state, even though under law, only government-run addiction clinics have the right to treat them.



Dr Khidirov is among those who maintain the number of drug users is rising rather than falling, although the situation is not as severe as it was directly after the end of the Tajik civil war in 1997, when the number of addicts was even higher.



He outlined a direct connection between the growing number of injecting addicts and the simultaneous growth in the infection statistics for HIV, hepatitis and other concomitant diseases.



“Every drug addict creates eight or nine others,” he noted. “The number of youth [addicts] is increasing, while the growth in the number of girls taking drugs causes particular concern,” he went on.



According to the Centre for Disease Control of the US Department for Health, which researches the incidence of HIV among injecting drug-users, in 2004 Tajikistan saw an increase in HIV infection of 12 per cent, in 2005 of 16 per cent, and in 2006 of 23.5 per cent.



METHADONE SEEN AS WAY TO CURB HIV RATES



Campaigners for reform insist that substitute therapies involving methadone could offer a way out for existing drug users and, by reducing the incidence of needle-sharing, restrain the growth in drug-related HIV infection.



They say it could also reduce crime levels among addicts who rob and steal in order to get drugs that they cannot afford.



The hope is that a degree of public control over the treatment and behaviour of addicts can be restored. The ultimate stage of the methadone programme involves preparing patients to come off medication altogether and return to normal life.



Dr Khidirov, an active supporter of substitute therapy, sees many advantages in this approach, having looked at the experience of other countries.



“Countries that use substitute therapy have stabilised new cases of HIV among injecting drug-users, and fewer crimes are committed,” he said. “People can return to their families, start planning a new life and look for a job.”



Pulod Jamolov, director of SPIN PLUS, a support group that brings together drug users and people living with HIV and hepatitis-C, agrees, saying the introduction of methadone therapy could bring new hope to many patients.



Jamolov says even when addicts are offered treatment in state-run clinics, it is expensive and often sub-standard, largely because the medical personnel are poorly qualified for this work.



When addicts are cured from their physical addiction, there is no psychological back-up or after-care. In any case, most addicts do not attend these clinics.



Dr Jamolov said the introduction of officially permitted medications like methadone might help alter the overall culture surrounding addiction, removing some of the element of shame and secrecy.



“This drug [methadone] is legal, no one will judge you for using it, you will not be imprisoned, and the state will not spend resources to keep you in jail,” he said.



“A certain dose of methadone is chosen for each addict for oral consumption. It enables them to move around and communicate normally and not suffer withdrawal symptoms.”



According to Jamolov, methadone will also help HIV-positive addicts make better use of anti-retroviral, ARV, therapies, which need to be followed according to a strict timetable. Drug addicts are notorious for violating the rules set for ARV treatment, as their main priority is getting a new fix.



OFFICIALS SAY NEW THERAPIES NOT SUSTAINABLE



The health ministry, while not totally against methadone in principle, has yet to be convinced, and many officials believe the introduction of substitute therapy would be premature.



They worry that in a country that depends so much on foreign aid to support public services, the scheme would not be sustainable. Foreign donors might provide methadone supplies for a time, but within a few years the aid would dry up, leaving Tajikistan with a project it could not maintain.



Secure storage and transportation of methadone are also causes for concern.



Safar Sayfiddinov, who heads the health ministry department for medical services, told IWPR that a working group was still studying the method and had yet to draw firm conclusions.



“We need to study international experience, and if there are countries that have rejected it for good reason and have studies, results and evidence to back this up, then [we] should not be doing it, either,” he said.



“If methadone is sold openly it will be for the worse. It too causes … addiction… It is like curing a patient of one substance and causing the same pathology with another.”



Latif Mingboev, chair of Salomat, a consumer association for medical services and pharmaceuticals, is equally sceptical. He maintains that treating addicts with other drugs cannot be effective in the long run.



“This is not a therapy, but the legalised provision of different drugs to addicts,” he said. “This false method must not be approved; there is no need for it.”



Mingboev argued that the main barrier to the further spread of addiction was the difficulty of obtaining drugs, the fear of legal prosecution and the expense.



“Moreover, our country is not in a position to buy these medications,” he said, referring to methadone. “We have so many problems - people are very poor. It would be better to help them [the poor] rather than helping addicts to receive free drugs.”



Aslibegim Manzarshoeva is an IWPR contributor in Dushanbe. Lola Olimova is IWPR’s Tajikistan editor.