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The public health case for reforming drug policy in Eastern Europe and Central Asia

Public health is facing a serious crisis in much of Eastern Europe and Central Asia. A range of social and economic factors, the remaining impact of Covid and the war in Ukraine are combining to continue the spread of infectious diseases, including HIV, hepatitis and tuberculosis. One key driver remains the lack of a coherent evidence-based and humane drug policy across the region. 

EECA remains a high burden region for injecting drug use with an estimated 2.2M people injecting drugs, the quadruple of global average and of that of Western Europe. 

The region is still home to the fastest growing HIV epidemic in the world with 1.8 million  living  with the virus and a prevalence of 1.1 percent amongst adults. The number of new HIV infections almost doubled in the last ten years and the number of  AIDS related deaths over the same period increased by a third. Significantly, 40 per cent  of new HIV cases are attributed to injecting drug use. People who inject drugs account for 60 per cent of all people who live with HIV in the region. 

The numbers for hepatitis are just as concerning. Two thirds of people who inject drugs are infected with Hepatitis C and 30 % are co-infected with HIV and hepatitis C. Despite there being a cure for Hepatitis C, only eight per cent of PWID are receiving treatment in the region.

The latest evidence indicates that the situation is not improving on either front. 

In 2020, 54 per cent of new HIV diagnoses in the region were detected at late stages of the disease, which is 10 per cent  more than in 2018. And only one quarter of people injecting drugs were aware of their Hepatitis C infection. Multi-drug resistant tuberculosis and overdose experience are highly prevalent. One third of people injecting drugs has a history of incarceration, every tenth has been engaged in sex work and had unstable housing.

WHO and UN agencies recommend implementing harm reduction strategies “to prevent major public and individual health harms, including HIV, viral hepatitis and overdose, without necessarily stopping drug use.” Harm reduction interventions include the provision of clean syringes and needles, opioid agonist therapy to treat opioid dependence, and the availability of naloxone for opioid overdose reversal. Despite the comprehensive evidence for the effectiveness of these interventions from across the globe, harm reduction is hardly accessible to people in need in most countries of the region.

Eastern and Central Europe and Central Asia is thus marked by high levels of high-risk drug use and slow progress towards health-based drug policies.

Establishing effective, health-based and responsive drug policies is more important now than ever in EECA with  several  external factors affecting the drug situation in the region: the war in Ukraine, increased opium production in Afghanistan since the Taliban’s return to power  and an overall increased prevalence of use of new psychoactive substances. Consequently, experts predict that this will result in increased drug availability, drug consumption and drug-related health impact, on a background of increasing prevalence of mental health issues. The changing geopolitics within the region have the potential to  provide new opportunities for drug policy reform: it has been  the impetus to set up  the Eastern and Central European and Central Asian Commission on Drug Policy (`The Commission)´, a group comprised of political leaders from the region and scientists whose main remit is to support open dialogue around an  evidence-based and human rights oriented drug policy and reform in the region. 

Meaningful drug policy reform in the region will require changes on a number of fronts.

The Commission believes that public health outcomes should be given a central place in shaping drug policy.  Effective harm reduction measures, which include syringe exchange programs, opioid agonists treatment (OAT), medical and social support to people who use drugs, can significantly reduce the negative consequences of drug use on people’s health. At the same time, this approach would both help prevent HIV, hepatitis and other infections transmissions and decrease drug-related crime and improving public safety.

It follows then that treatment for drug dependence should follow international standards. Treatment should be voluntary with informed consent, offering an integrated set of care that addresses health, social and legal needs, be based on realistic, individualized treatment plans, be appropriate and accessible, particularly for women and prisoners, allow an easy entrance, avoid automatic involuntary discharge as a disciplinary measure for failed drug tests, and offer outreach and low-threshold interventions for people not motivated for structured forms of treatment.  

This approach also means ensuring full access to controlled substances as medicines. Morphine, methadone, and buprenorphine are included in the WHO Model List of Essential Medicines, recognizing their critical role for pain management and palliative care and in the treatment of drug dependence. However, Eastern Europe and Central Asia remain significantly behind in terms of access to and the uptake of morphine and other opioid pain treatment.

Human rights are also fundamental to reform. Using drugs should not be grounds for liberty deprivation or restriction of political, economic, social and cultural rights. Drug policy should be designed with respect to human rights and respective international conventions which are ratified by nation states.

Decriminalization of drug use and possession for personal use will ultimately be part of the equation too. They are both being recommended by WHO, UNAIDS, the UN System common position on drugs of 2018 and supported by systemic scientific reviews. Penalizing people who possess drugs for personal use does not prevent people from using drugs. Applying criminal sanctions to people for drug possession and use while causing no harm to others is disproportional. A criminal record hampers reintegration of people into society; criminal penalties contribute to over-incarceration which is among the highest in the world in the Russian Federation and several other EECA countries and drives the spread of infectious diseases.

Finally, decriminalization would be hopefully accompanied by a reduction in incarceration rates for drug offences.  Eastern Europe and Central Asia have one of the highest rates of incarceration globally. Drug offences and non-violent property crimes related to drug use (some call them economic-compulsive offences) significantly contribute to these over-incarceration rates. 

Aleksander Kwasniewski, was the President of Poland 1995-2005 and is the Chair of  the Eastern and Central European and Central Asian Commission on Drug Policy