Kicking habits, kicking back; In Russia, a punitive Soviet approach to drug users is still in place. But a new generation of activists is ready to challenge it.
(opendemocracy.net – Dmitry Lebedev – February 20, 2017)
Dmitry Lebedev is a freelance journalist from Moscow. He holds a Master’s research degree in political philosophy from Radboud University, Nijmegen, Netherlands.
When Russian media report an increase or decrease in drug addiction in the country, they are usually only reflecting the number of users officially registered at state clinics. The practice of putting anyone requesting treatment for drug abuse on the drug users’ register traces its roots back to the Soviet era, but it has made a smooth transition.
Once registered, people find that their rights are subject to various restrictions: they are banned from certain types of work; they can’t get a driving licence or residence permit, or adopt a child. The very fact of being on the register also stigmatises them as addicts, fostering social isolation and humiliation. And even if they manage to overcome their addiction and come off the register, that doesn’t guarantee that the stigma goes away.
People who use know this, and those who could come off drugs are wary of asking for treatment. This makes it very difficult to even guess the real numbers. As for their civil rights, the NGOs working in this area lack the resources to provide much help: last year, for example, both the Moscow-based Andrey Rylkov Foundation for Health and Social Justice and Project April in Tolyatti were declared “foreign agents”, a status that brings with it numerous financial inspections and court appearances, and considerably complicates the organisations’ work.
Last December, the Mayor’s Office in Tolyatti, a large city with a reputation for drug problems and high HIV figures, announced that the number of its citizens on the drug user register had fallen by 1.3%. Many in the media, as usual, interpreted this as “a fall in the number of drug addicts”. One Tolyatti resident taken off the register was Ivan Anoshkin, who was, until recently, on Desamorphine, an opioid derivative of codeine with the street name of krokodil. Anoshkin now works with Project April on programmes to help other addicts off drugs.
Ivan’s story is not just about how he recovered from his addiction, but about his battle with the inert and retrograde institution that is Russian narcology as a whole – and the drug users’ register is a key element of it.
Surveillance and punishment
Ivan Anoshkin started using drugs in 1994 at the age of 14. His addiction led to three jail sentences on theft charges and by 2010 he was in a sorry state: his health was wrecked by krokodil and he had no money for proper treatment.
That was the year he finally turned to Tolyatti’s state drug addiction clinic and agreed to undergo treatment. This, however, didn’t last long. Russian narcotics specialists, despite the recommendations of the international medical community, still base their therapy programmes on tranquillisers and anti-psychotics. As an in-patient at the clinic, Ivan was forced to take unfamiliar medication that muddled his brain and left his body helpless.
Another part of the problem was the hostile and arrogant attitude of clinic staff. After one attempt to escape and find drugs, Ivan was forced to spend a night tied down in his bed, unable even to go to the toilet. Unable to kick his habit, he returned to the clinic five times but failed to complete a detox course even once. He only finally went into remission with the help of the Andrey Rylkov Foundation and Project April, which promote a more humane approach to drug issues, as well as a users’ mutual support group.
Ivan came to the media’s attention while he was still drug dependent: he heard about the effectiveness of drug replacement therapy (which is banned in Russia) and wrote to the Ministry of Health asking to be prescribed methadone and buprenorphine, the drugs most commonly used elsewhere to treat opioid addiction. His request was, of course, refused, so he took his case to various courts and eventually filed a lawsuit with the European Court of Human Rights. Another case Ivan filed attracted less attention: he demanded the abolition of the drug users’ register, on which he had automatically been placed as soon as he checked into the clinic.
As Ivan recalls now: “I knew from friends about the downsides of being registered, but at the time I had no alternative. I hadn’t left my flat for years and was basically dying. They gave me a bed at the clinic and since then I have been an official Russian drug addict, complete with the side effects of that status – social stigmatisation, restricted access to work and a driving ban.”
In early 2016, after a routine clinic appointment (compulsory for anyone on the register) Ivan discovered, to his surprise, that traces of cannabis had been found in his blood, although he had been clean for a year. This sent him back to square one – and another three years on the register. After long and pointless correspondence with the Health Ministry and the drug clinic, he decided to take his case to a civil court with the help of the Rylkov Foundation. This case was less about the restrictions of Ivan’s rights and the fact of being on the register, but questions of procedure. According to the law, registration was completely voluntary, i.e. Ivan had to give his written permission to be placed on the register – a technicality that, in his case, had not been adhered to. Having discovered this legal anomaly, he began his battle with the Ministry and the narcology community.
Despite the fact that Ivan’s complaint was officially against the Health Ministry, it was the local drug rehab clinic that acted as the respondent. They presented a whole pile of papers supposedly confirming the correctness of Ivan’s inclusion on the register. The difficulty with this kind of case is that patients can’t prevent their names from being included in the register, and it’s difficult to prove that it has been done illegally, i.e without their written consent. As police officers acting as witnesses in court admitted, an agreement to have treatment means, effectively, an agreement to being placed on the register, which judges can accept as a convincing argument – especially if the litigant is a former or current drug user.
After several sessions, the court took the Ministry’s side. But Ivan refused to accept this verdict and took his case further up the judicial ladder.
What is the drug users’ register and how did it come about?
The drug users’ register is, in its present form, a system set up in the twilight years of the Soviet Union and based on a joint directive issued by the Ministry of the Interior and the Ministry of Health from May 1988. The directive required all individuals using psychoactive substances to be forced to undergo treatment, placed on a register and have regular examinations by a psychiatrist specialising in addiction – for five years in cases of drug dependency and one year for casual use.
Nowadays, both compulsory treatment and compulsory registration are banned. But while treatment at a clinic is now truly voluntary, in practice registration never is. It is automatic, so that many users are either unaware of their official status as an addict, or find out by accident – when they are issued a narcotics report to give a new employer, for example.
As Timur Madatov, a lawyer with the Rylkov Foundation, says: “the register has been, and remains part of the health system, despite the fact that all Soviet directives connected with narcotics use have been revoked. Now the so called clinical monitoring is regulated by a Ministry of Health directive of 30th December 2015, covering procedures for routine checkups, when they should be discontinued etc.” This document doesn’t even contain the words “drug users register”, but the requirement for three years of remission before checkups can be dropped is basically just a shorter version of the former five year registration period, and which psychiatrist Vladimir Mendelevich describes to me as a “cosmetic measure”, designed to massage the statistics.
According to the new rules, users must give written consent for regular checkups, while the doctor carrying them out must complete a questionnaire on them, the responses to be included on the register database. But given that being on the register means losing certain rights, and is a form of surveillance more appropriate to police officers than medical personnel, not every user is willing to be included in the register.
In fact, the very phrase “voluntary registration” sounds like an oxymoron in this context, and as a result, registration is happening “under the counter” – automatically, without users’ consent. It has therefore become a judicial anomaly that seriously affects citizens’ civil rights and poisons their daily lives.
Another “cosmetic” but equally unsound practice is the current system of anonymous treatment. This involves no register and no infringement of patients’ rights, but instead involves payment.
This means that people with little in the way of cash, such as Ivan Anoshkin, have no means of avoiding registration, while other people with similar dependency needs but more money lose none of their rights. They can happily drive cars, apply for any job they choose, and not worry about having their children taken into care.
As Human Rights Watch rightly points out, “the financial situation of the patient is not a legitimate criterion on which to judge whether their personal details should be included in a database and used to limit certain of their civil rights”. This is, however, the logic behind the whole edifice of Russia’s current approach to its drug problem.
Making criminals of addicts
The original, Soviet formulation of the drug users register was partly drawn up by the law enforcement agencies, which casts serious doubt on its medical credentials.
As Lev Levison and Mikhail Torban of Russia’s Institute for Human Rights, the register is “a tool of punitive psychiatry” that makes no sense in either statistical or medical terms. They believe that its sole raison d’etre is as an instrument for policing the public. As psychiatrist Vladimir Mendelevich says: “The register was not thought up by narcology specialists. Regular monitoring is essential in certain medical disciplines to prevent flare-ups of chronic conditions. The assumption is that patients have rights and voluntarily choose this pattern of interaction with medical professionals. In the case of drug users, however, the principle of regular checkups has ceased to be about medical procedures and has become an instrument of social control and loss of patients’ rights.”
Both the Soviet and the current drug users register are examples of a practice that, under the pretence of care for, and ongoing monitoring of, people living with drug dependency, brings with it stigma and restrictions on their rights for several years after they have begun treatment. Given that removal from the register, and thus a restoration of their normal rights, requires a lengthy period of remission (in 2015, only 3% of users were taken off the register), many people are simply trapped within the system.
Narcotics specialists justify the existing system by claiming that it promotes public order. According to this logic, drug users, with their limited rights and constant medical surveillance, are highly unlikely to threaten the social order.
As Vladimir Mendelevich says, the present system is a hangover from Soviet times, when narcology specialists were pressed into service as “sanitary inspectors”, to deal with unruly dissidents. And, according to Mendelevich, “most of our narcologists still adopt a repressive approach to their work. They often think of themselves as citizens, not as doctors.”
As a result, the drug users’ register has become an ideological tool for weeding out the “deviant” and the “abnormal” in the name of preserving some kind of social order. The effectiveness of this strategy remains, however, in doubt. According to Mendelevich, “the experience of most European countries, which have no such procedures, shows that there are more effective and reasonable ways to help prevent lawbreaking by drug users. They see no reason to deny driving licences to people on the sole basis of a diagnosis of narcotics dependency. Moreover, out of every 100 drivers caught under the influence of alcohol behind the wheel, there will be only one registered drug user.”
Apart from restrictions on civil rights, the users’ register has yet another negative side – as a punitive measure. Although narcology specialists have no right to share confidential information about their patients with third parties and state organs (apart from occasional and legally permitted cases where criminal investigations are involved), users are often caught up in a “revolving door” policy between the medics and the police.
To quote the Human Rights Watch report, “it appears that some Russian drug clinics share personal details of people on the register with the police and other government bodies.” Ivan Anoshkin tells me that after unsuccessful courses of treatment in state clinics, he came to the notice of the police and was eventually arrested, beaten up in the local police station and charged with possession of drugs (which the cops had planted on him).
Fortunately, Ivan escaped an actual prison sentence, and after he lodged several complaints, the suspended sentence has had been given was also rescinded. This individual case is, however, symptomatic of a widespread approach, where people on the drug users register are vulnerable to blackmail, extortion and abuse of police powers.
How the register does more harm than good
The most negative aspect of the drug users’ register is probably the fact that it scares off people who might go for treatment, if that didn’t mean losing some of their civil rights.
In 2015 there were 544,563 addicts on the register, but according to the police, the real number of drug dependent Russians runs into the millions (Russian link). Knowing the consequences for their rights, and the corruption and inefficiency in the health service, many users try to avoid the state health sector – only to fall into the hands of charlatans in religious or occupational rehab centres where they can forget about any rights at all. So the original idea of preserving public order is, in practice, turned on its head: the attempt to monitor drug users pushes them “underground”, and even further marginalises them, rather than offering professional treatment and a potential return to normal life.
The register undermines trust between doctor and patient – the user sees the medic as part of the law enforcement system, only interested in checking whether they have “gone back on the hard stuff”
Another problem with the register is that it doesn’t allow a personal and trust-based relationship with users – they become mere statistics, their rights abused and unable to influence their situation in any way. “At the clinic they looked at me like I was a traitor,” Anoshkin tells me. “And as I tried to exercise my rights, I was faced with a wall of prejudice. But I’d always thought of a doctor as someone I could trust, someone with a sense of duty and with whom I could have a friendly relationship.”
The register is in fact one of the chief obstacles to forming such relationships. As lawyer Timur Madatov says, “The register is a real hangover from the past, that only gets in the way of doctors treating addicts, since the creation of trust between doctor and patient is an essential part of effective treatment. The register undermines this trust: a visit to a doctor is seen as a box to be ticked and the medic becomes part of the law enforcement system, only interested in checking whether the user has “gone back on the hard stuff”.
Psychiatrists Levinson and Torban agree with this analysis: “the regular check up system is not focussed, as it should be, on preventing relapses and helping the user if they have relapsed or are in danger of relapsing, but just on recording whether they have taken drugs or not since their last visit.” So instead of having a right to rehabilitation, the addict is just forced to regularly report to the clinic, which is pointless from a treatment point of view.
There is another factor here that might explain the amazing longevity of the register. The fact is that Russian narcology is currently experiencing a severe deficiency in both the quality and quantity of its practitioners. Most narcotics specialists have come up through the repressive Soviet system and see nothing odd about the continued existence of the register. At the same time, their numbers are dropping year on year, so that some doctors are seeing up to 40 patients a day. According to Timur Madatov, “the situation is critical and only getting worse. And abolishing the register at this point would probably just mean more users looking for help, something the system simply couldn’t cope with.”
The parlous state of the medical system also means that users are being constantly exhorted to take personal responsibility for their condition, accused of not wanting to get better and generally made to take the blame for the whole situation.
Collective resistance
The latest court session in Ivan Anoshkin’s case took place on 30 December, and this time at regional level, with the Samara Region Narcology department as the defendant.
It was no surprise that no one from either the department or the Ministry of Health turned up, the session lasted a mere five minutes and Anoshkhin’s complaint was once again thrown out. He had been called for his final check up a few weeks earlier: his time on the register had supposedly expired. There was no logic to this: with the traces of cannabis discovered in his bloodstream two years before, under the new regulations he should theoretically have been monitored for another year.
Ivan believes that his progress through the courts has had an effect: “The Ministry of Health still couldn’t accept that it had acted illegally, and so decided to take me off the register early instead. They also expunged my conviction for possession, when the drugs had been planted on me. The system decided to draw a line under my whole case, but they still won’t admit any mistake.” So Ivan’s unlawful inclusion on the register ended with a correspondingly unlawful removal from it.
Despite not winning his case in Russia’s courts, Ivan still plans to take it, with support from lawyers, to the European Court of Human Rights. Timur Madatov believes that “winning a case against government bodies in a national court is always highly unlikely. Whereas if we can take Ivan’s case as far as the ECHR, I think that at the very least, the infringement of his right to voluntary informed agreement to medical treatment will be recognised under Article 8 of the European Convention on Human Rights, which embodies ‘a right to respect for one’s private and family life'”. The situation is complicated by a recent government directive giving decisions taken by Russia’s Constitutional Court priority over ECHR verdicts – the outcome is impossible to predict. Nonetheless, this attempt to test the Russian narcology establishment’s ability to cope with stress and force it to admit its mistakes seems perfectly reasonable per se.
In a country where the norm is not the protection of human rights, but a systemic resistance to protecting them, where drug users are considered responsible for the ineffectiveness of the clinicians supposedly treating them, and where over 50% of the population believe that drug use should be a criminal offence, protecting the rights of drug users and addicts would seem to be a lost cause. Ivan Anoshkin’s case shows that institutional shortcomings can, and should, be exposed.
Ivan’s story is less a classic Kafkaesque parable about the little man challenging the state machine, than a demonstration of how the law can be used to collectively resist repressive institutions on legal grounds. Neither Ivan’s recovery from addiction nor his path through the courts would probably have been possible without help from others.
This case shows the effectiveness of collective solidarity against the ideological rhetoric about personal responsibility. The familiar Russian scenario, where an individual is pitted one on one against the institutional abuse of their rights or banal ineffectiveness, only leads to the further erosion of human rights and the half-dead public institutions themselves – and the first to be affected are vulnerable groups such as people who are drug users and or living with HIV. In this context, any collective attempts to oppose this erosion become particularly important.
Article also appeared at opendemocracy.net/od-russia/dmitry-lebedev/kicking-habits-kicking-back bearing the following notice:
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