Improvement of Treatment of Drug use Disorders in Central Asia the contribution of The EU Central Asia Drug Action Programme (CADAP)
- 1. Federal Ministry of Health, Germany
- 2. Trimbos Institute, The Netherlands
- 3. Faculty of Health and Social Work, Frankfurt University of Applied Sciences, Germany
- 4. Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), CADAP Office Bishkek, Germany
REFERENCES
1. Council of the European Union: Regional report on Central Asia, Dublin Group. 2013; 39.
2. Council of the European Union, 2014: Regional report on Central Asia, Dublin Group, 2015; 56.
3. Council of the European Union, 2013: Regional report on Central Asia, Dublin Group. 2015.
7. OSCE. Information Bulletin on drug related situation. The Central Asia Region. 2013.
8. OSCE. Information Bulletin on drug related situation. The Central Asia Region. 2014.
12. AIDS Foundation East-West. Annual Report 2014. 2015.
13. AFEW: Annual report 2014: Country profile Kazakhstan. 2014.
14. CADAP Mission report Kazakhstan, I. Michels. 2016; 25-29.
15. EMCDDA: country overview Kazakhstan. 2015.
19. Alex Chingin and Olga Fedorova, Country profile Kazachstan. Pompidou group. 2014.
20. UNODC/Paris Pact: country fact sheet Kazakhstan. 2015.
24. UNODC; Methadone Maintenance Therapy in Kazakhstan (introductory note to MMT conference). 2015.
25. Michels I, CADAP. Mission Report the Kyrgyz Republic. 2015; 20-24.
26. EMCDDA. Country overview Kyrgyzstan. 2014.
28. Stoever H, Michels I. CADAP mission report Tajikistan-Kyrgyz Republic. 2015.
29. Trautmann F. CADAP mission Tajikistan. 2016.
30. CADAP: First meeting National Steering Committtee, Tajikistan. 2016.
31. DCA Tajikistan: Review of the situation with narcotic drugs. 2014.
32. DCA Tajikistan: Review of the situation with narcotic drugs. 2015.
33. Eurasianet: Tajikistan: On Afganistan’s Heroin Highway, Corruption Fuels Addiction and HIV. 2012.
34. National Center of Monitoring and Prevention of Drug Use: Needs and Proposals. Dushanbe. 2016.
35. EMCDDA: Country overview Tajikistan. 2014.
36. NGO Law Monitor: Tajikistan.
37. NGO -ROST: Analysis of the legislation in the sphere of drug policy, Survey report. Dushanbe 2010.
38. NGO -ROST: Presentation report legislation, Dushanbe. 2016.
39. UNODC/Paris Pact: country fact sheet Tajikistan. 2015.
41. I. Michels. CADAP mission report Uzbekistan. 2016.
42. EMCDDA: Country overview Uzbekistan. 2014.
43. NCDC Uzbekistan: Analysis of drug situation in Uzbekistan for 2014.
44. NCDC Uzbekistan: presentation given during CADAP ass mission. 2016.
45. NGO Law Monitor: Uzbekistan.
46. UNODC/Paris Pact: country fact sheet Turkmenistan. 2015.
48. NGO Law Monitor: Turkmenistan.
49. Alex Chingin ,Olga Fedorova. Country profile Turkmenistan. Pompidou group. 2014.
50. US State department, Bureau of International Narcotics and Law Enforcement Affairs, 2014.
51. US State department, Bureau of International Narcotics and Law Enforcement Affairs, 2015.
Abstract
According to 2009–2013 and 2014 – 2020 Action Plans on Drugs between the European Union (EU) and the Central Asian states it is of common interest to address drug-related concerns, to intensify cooperation and to provide assistance in the field of drug prevention and drug treatment. Central Asian countries (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan) are experiencing drug use related problems, such as increasing numbers of drug dependents (approx. 400,000 injecting heroin users) and the threat of infection diseases such as HIV and Hepatitis among injecting drug users (with a prevalence of 4-20%, 50-70% respectively). Several harm reduction programmes had been launched, but mostly externally donor-driven.
Although the model of “narcology”, in the sense of social control rather than strengthening of self-support and respecting human rights of drug users, still exists, a common basis for improvement of drug prevention and treatment response is already on the way. Drug dependence is defined as a chronic illness and treatment is seen to be needed. The staff in the treatment and rehabilitation centres is qualified and highly motivated, but the structural barriers and lack of funding are omnipresent. There is an urgent need for exchange of experiences and trainings in psycho-social support and new methods of psychotherapy and implementing and scaling-up of Medication Assisted Treatment (MAT). Several bottlenecks and threats for further improvements of the services for drug users exist. Although detoxification and short term inpatient treatment facilities exists on the basis of the primary care system, only limited out-patient treatment facilities are working. There is only very limited access to Opiate Substitution Treatment (OST) and only limited co-operation of HIV, Hepatitis, and TB prevention services for injecting drug users and addiction treatment centres. The EU financed “Central Asia Drug Action Programme” (CADAP) is aiming at supporting the need for further qualification and trainings in psychotherapeutic methods for brief interventions, motivational interviewing, relapse prevention and social rehabilitation, and MAT. More than 2,000 experts and governmental representatives were trained between 2010 and 2012. Access to OST could be slightly increased in Kyrgyzstan, Tajikistan and Kazakhstan. In the current 6th phase of the programme the improvement of the institutionalisation of the treatment system and the WHO/UNODC International Standards of the Treatment of Drug Use Disorders will be trained and systematized, using EU best practices.
Citation
Michels II, Keizer B, Trautmann F, Stöver H, Robelló E (2017) Improvement of Treatment of Drug use Disorders in Central Asia the contribution of the EU Central Asia Drug Action Programme (CADAP). J Addict Med Ther 5(1): 1025.
Keywords
• Drug situation in central asia
• Opiate use
• Treatment of drug use disorder
• Opiate substitution treatment (OST)
ABBREVIATIONS
AFEW: Aids Foundation East West; CA: Central Asia; CADAP: Central Asia Drug Action Programme (EU); CARICC: Central Asian Regional Information and Coordination Centre for Combating Illicit Trafficking of Narcotic Drugs, Psychotropic Substances and their Precursors; DCA: Drug Control Agency; EMCDDA: European Monitoring Centre for Drugs and Drug Addiction; GFATM: Global Fund to Fight AIDS, Tuberculosis and Malaria; IDU: Injecting Drug User; MCAD : Monitoring Centre for Alcohol and Drugs (Kazakhstan); NPS: New Psychoactive Substances; OSCE: Organisation for Security and Cooperation in Europe; OST: Opioid Substitution Treatment; TREAT: Treatment Methodologies Component of CADAP; MAT: Medication Assisted Treatment
INTRODUCTION
The Central Asia region countries Kazakhstan, the Kyrgyz Republic, Tajikistan, Turkmenistan, and Uzbekistan -- include more than 60 million ethnically, culturally, and religiously diverse people distributed over a geographical area twice the size of continental Europe. Located at the centre of the Eurasian continent, these landlocked countries, which became independent when the Soviet Union dissolved in 1991, comprise one of the poorest regions of the world1 Since independence, they have faced the huge challenges of nation building, creating new constitutions and organs of government. Policy makers confronted the legacy of the past with structures, such as their health systems, that are inappropriate to today’s needs, unaffordable and in urgent need of reform.
The ultimate responsibility for shaping national health systems lies with governments. Shaping does not suggest that governments should – or even could – reform the entire health sector on their own. Many different groups have a role to play: national politicians and local governments, the health professions, the scientific community, the private sector and civil society organizations, as well as the global health community. Nevertheless, the responsibility for health that is entrusted to government agencies is unique and is rooted in principled politics as well as in widely held expectations.2
Today, Central Asia (CA) has become a key region for the international activities tackling the illegal drugs and related problems – specifically the problems with illegal opioids, and increasingly, also cannabinoids. Drugs and drug related crimes are key challenges for the international community and each state. Drug phenomena challenge the authority of state institutions, the social cohesion of the society, public health and the security of public life.
The fact that the “Northern Route”, with trafficking heroin, morphine and opium towards Russia and Europe, crosses CA has made that region not only vulnerable to drug trafficking, but - increasingly - also to local drug consumption. The necessity to address both sides of the drug problem (supply and demand) has clearly been recognised by the five CA countries and is also reflected in their national strategies and/or state programmes on drugs.
The European Commission has supported the five partner countries’ for several years when trying to alleviate the negative consequences of drug trafficking and drug use through its multi-phase Border Management in Central Asia Programme (BOMCA) and Central Asia Drug Action Programme (CADAP). While BOMCA continues to promote in particular the concept of Integrated Border Management, CADAP supported a balanced drug policy through the focus on both drug demand and drug supply issues, in line with the EU Drug Strategy 2013-2017 and the EU Central Asia Drug Action Plan 2014-2020.
According to the annual reports of the drug situation in 2012 and 2013 – compiled by four of the five countries - there are first signs of a reduction of drug dependency (at least of the officially registered persons with drug dependence). It is difficult to analyse the reasons for this trend, but this trend can be stabilized by a common initiative of CA countries to tackle these drug related problems on a regional level. (24)
All countries in Central Asia are supporting the common view of the UN bodies (UN Drug Convention 1961, Art. 38; and Political Declaration 2009) to implement all practicable measures for “prevention, early identification; treatment, education, after-care and rehabilitation and social reintegration” of drug dependent people.
According to the UNGASS 2016 outcome document “Our joint commitment to effectively addressing and countering the world drug problem” should be cited instead? There it says: “We recognize that the world drug problem remains a common and shared responsibility that should be addressed in a multilateral setting through effective and increased international cooperation and demands an integrated, multidisciplinary, mutually reinforcing, balanced, scientific evidence-based and comprehensive approach”.
All CA countries implement Drug Strategies that take these principles into account.
Nevertheless, some general lessons learnt from CADAP V phase should be taken into account:
- CADAP partners underlined the reliable and fruitful cooperation and highlighted various achieved results. National and regional activities have taken place in all five countries within the framework of the Components OCAN, DAMOS, TREAT and MEDISSA. Study visits to EU member states have strengthened the cooperation between CA and EU institutions and experts in drug policies;
- Modern and effective approaches exist in all countries but lack institutionalization and require further scaling-up and harmonization.
- The political and institutional commitment of CA governments is a key factor for the successful implementation of the programme;
- Drug policy is still mainly focused on supply reduction; it is mostly seen as a security issue, not as a public health issue;
- The coordination mechanisms are based mainly in the Ministries of Interior, not in the Ministries of Health;
- Capacity building activities are effective and efficient. Nevertheless, all partners demand financial and technical support as well;
- In order to secure sustainability, activities should seek for a mid- to long-term perspective of results;
- A regional understanding is still missing; but while regional in scope, CADAP implementation has to be tailor-made and to focus on each country’s specific needs and priorities;
- It is expected that the successful implementation of strategies and mechanisms in one CA country can lead to regional learning effects and regional harmonization in the area of drug policies.
- Active donor coordination has been lacking in the past, leading to aid ineffective practices. International donors regard their specific objectives and visibility of their (bi-lateral) programmes more important than the long-term contribution to a joint overall objective;
- The CA countries lack in terms of cooperation. The political relations between some countries are rather difficult;
- NGOs, an important part of efficient and sustainable drug policies are weak in all countries and lack the basis of work. [1-9] (Figure 1), (Graph 1 and 2).
OVERALL OBJECTIVE OF THE EU CENTRAL ASIA DRUG ACTION PROGRAMME (CADAP) PHASE VI
- The overall objectives of the proposed six phase of CADAP are the gradual adoption of EU and international good practices on drug policies and to contribute to the reduction of drug production / drug-related problems.
- All project activities focus on national and trans-regional capacity building. Each target institution is expected to strengthen its capacities in the fight against drugs / drug-related problems and increase its accountability of information management in this field.
- CADAP 6 is divided into four specific components with specific objectives. All components are led by highly experienced Component Leaders (CL). The Component Leaders will resort to experts from various EU Member States institutions.
- Component 1: National Drug Strategies (NDS). Component Leader: Trimbos Institute, Utrecht, The Netherlands
- Component 2: Nation Focal Points on Data Collection. Component Leader: ResAD, Prague, Czech Republic
- Component 3: Drug Prevention. Component Leader: National Bureau for Drug Prevention, Warsaw, Poland
- Component 4: Treatment. Component Leader: Frankfurt University of Applied Sciences /Institute for Addiction Research, Frankfurt/M, Germany
Objective of the Component 4: Treatment
In the field of drug demand reduction, the objective of the EU Drugs Strategy is to contribute to the reduction of drug problems in the society. The activities in the region to achieve this objective need to be evidence-based and follow the following assumptions:
- A better coverage and accessibility of high quality drug treatment, both pharmacological and abstinenceoriented, and its combination with rehabilitation and reintegration is needed in CA, offering a wide range of integrated pharmacological (such as detoxification and opioid agonist and antagonist treatment) and psychosocial (such as counselling, cognitive behavioural therapy and social support) interventions based on scientific evidence and focused on the process of rehabilitation, recovery and social reintegration.
- The programme is to strengthen harm reduction efforts aimed at reducing the adverse consequences of drug use for individuals and society as a whole, taking into consideration not only the prevention of related infectious diseases, such as HIV, hepatitis B and C and tuberculosis.
- Drug Demand Reduction Programmes shall be based on the “Principles of Drug Dependence Treatment” from UNODC and WHO (2009) and the UNODC/WHO “Joint Programme on Drug Dependence Treatment and Care” from 2009 and the UNODC “Treatment Quality Standards” (2013) as well as the “WHO / UNODC International Standards of Treatment of Drug Use Disorders” (2016), applied to Central Asian countries in line with their revised/or newly adapted national strategies on drug demand.
- ‘’Atlantis” drug addict treatment programmes in prison systems (“Atlantis” drug-free treatment unites) are important, but not the only option, whereas comparable treatment programmes such as Opiate Substitution Treatment (OST) shall be institutionalized in the long-run in all Central Asian countries.
- The aim is to establish an official network of professionals. The key expected results are:
- Health care and social responses to tackle drug use in the region increased.
- Best practices and better quality services for drug users consolidated (Graph 1).
Drug Situation in Central Asia
Drug Situation in Kazakhstan: Kazakhstan is by far the largest of the Central Asian states of the former Soviet Union. It has borders with Russia, China, and the Central Asian countries of Kyrgyzstan, Uzbekistan, and Turkmenistan.
It is the world’s ninth biggest country by size, and it is more than twice the size of the other Central Asian states combined. Population size is about 16,5 million. GdP size in 2011 was USD 11,220, which is relatively high, mainly due to gas and oil reserves. As prices of these commodities have dropped in the last years, this has put pressure on the financial status of the country.
Kazakhstan has the ambition to belong to the 50 most developed states in the world in 20203 , however without developing a democracy comparable to most of the western countries.
Kazakhstan is a transit country for Afghan opiates destined for Russia, wild cannabis and ephedra grow in the south of the country. Kazakhstan lies on one of the two main heroin routes from Afghanistan into Russia. Some of this supply continues onward to Europe.
Potent drugs like heroin are basically imported from both neighbouring and far-abroad countries. The key external source is Afghanistan. As experienced globally, strengthening the control of illicit trafficking of traditional narcotics such heroin, cannabis and opiate leads to filling the “black market” with other easily accessible types of new types of narcotic drugs. There is a threat of spreading synthetic narcotics (Spice) both produced within the country as coming from neighbouring Russia and China, as well as from European states. The official data show that over the past 7 years the volume of seized4 synthetic drugs has increased from 165 kg to 22 tons.5
The latest study of the prevalence of drug use among the general population on a nationwide scale was conducted in 2001 by the Republican Scientific and Practical Centre of Medical and Social Problems of Drug Abuse (RSPC MSPDA). According to the data obtained in the above-mentioned study, the number of people dependent on drugs in the Republic of Kazakhstan was 1.7% of the total population. Of these, 31.6% were individuals dependent on opioids (mainly heroin addiction), 81.3% were individuals dependent on cannabis, and 15.5% individuals dependent on other drugs. 10% of the respondents had used drugs at least once in their lifetime.6 In accordance with the international definition, problem drug use (PDU) in the Republic of Kazakhstan is attributed primarily to injecting drug use (PWID). There are no reliable data on the problematic use of cocaine, amphetamines, and methamphetamines among the population of Kazakhstan. It should be noted that the high cost of these drugs in the country significantly limits their availability; most of the substances were seized in the cities of Astana and Almaty. Recently, problems related to the [emergence of desomorphine (Crocodile) in the country have become relevant. Estimated number of injecting drug users: 2010: 119,100; 2011: 123, 640; 2012: 116,840; 2013: 112,740; 2014: 127,8007 . There is a decrease in the last three years of the total number of registered drug users, mainly heroin users (see data of MCAD and below: treatment demand), but it is unknown what the reason is, considering the increase in estimated PWIDs8 [10-21].
Drug use in prisons: In 2011 a system of monitoring and assessment of the drug situation in Kazakhstan was set up within the correctional institutions. As of 31 December 2013, there were 44,893 prisoners in correctional institutions in Kazakhstan. Of the total number, more than 10% (6,099 people) were registered as addicted to psychoactive substances and alcohol. There were 2,963 PWIDs under supervision as of 31 December 2013.
The prevalence of HIV infection in Kazakh prisons as of 31 December 2013 was 1,641 people. The prevalence of HIV infection in prisons was more than 45 times higher than in the community (36.6 and 0.8 per 1,000 respectively).9
There are not many reliable and up to date data available on drug use in prisons. If there are any statistics, the problem is that foreigners in prisons are not taken into the statistics. According to some stakeholders there is drug use and drug dealing in prisons and consequently transmission of infectious diseases, and there are even cases mentioned of some people starting drug use in prisons.10
Treatment of drug dependents in Kazakhstan: The main providers of addiction treatment in the country are drug treatment clinics, which cover about 90% of all cases of treatment for drug dependence in the country. The availability of a budget for outpatient treatment in some regions of the country (especially in rural areas) may be limited by the lack of primary health care (PHC) and lack of professionals in addiction treatment. Moreover, budgetary limitations on inpatient treatment result in the low accessibility of treatment for persons from remote areas and villages.
In the public sector, the hospital treatment of patients with drug and alcohol addiction is provided by drug treatment clinics, psychiatric hospitals, and addiction clinics for compulsory drug treatment. Treatment in therapeutic communities with government support is carried out by two organisations in the country.
Outpatient drug treatment is conducted in cities by the departments of urban and regional drug treatment clinics, in small towns by the dispensary departments of psychiatric clinics, and in rural areas by drug advisory spots.
The bulk of the help provided in outpatient substance abuse treatment is performed by public health organisations; some help is provided by private medical organisations. Also NGOs play a role in demand reduction and the medical and social rehabilitation of dependent drug.11
The Kazakh Officials expressed their readiness for further cooperation with the CADAP. The Ministry of Health and Social Development decided to merge the Almaty Neurological centre with the Pavlodar centre (Republican Narcological Centre as centre of excellence)in order to work together on a comprehensive approach on treating the addiction problematic, including (legal) alcohol and tobacco addiction and the gambling problematic as well as illegal drugs’ problem (heroin and cannabis) and New Psychoactive Substances (NPS). The new merged centre will organize national trainings and develop national standards. The Pavlodar centre will be still responsible for developing prevention programmes according to the State Health Programme “Densaulyk 2016 – 2019”. The focus will be given to local out-patient centres (at polyclinics and family doctor’s centres). The Pavlodar centre in co-operation with the Almaty centre will provide expertise for addiction policy towards the Ministry of Health. The MoH will prove and approve their recommendations. Regarding OST, the Office of the Chief Prosecutor supported the further development of OST sites and expressed the willingness to accept the competence of the health experts in this regard [22-24] (Table)
In 2015 32 narcologists had been trained on OST in Lithuania at the University of Health on European Standards. Although the Ministry of Health, together with significant numbers of other stakeholders, has declared its support for OST (and has registered this as a medicine), there is still no clear decision on the introduction of OST as a regular form of treatment in Kazakhstan. Opponents can be found in police/security circles12. Their main argument against OST is that methadone is a drug, and once this drug is allowed as a medicine, tolerance towards other drugs is inevitable. Anyway, Methadone is now registered in Kazakhstan as a controlled drug, so it can be ‘legally’ provided for OST sites. A Kazakh company will produce it in 2016 in cooperation with a Polish company. But there are still obstacles in OST-Treatment: a) an opposition against OST by medical professions and law enforcement agencies b) patients are afraid of being registered. Regarding methadone treatment for opioid users, pilot projects are working for several years, but there is still not seen a progress in scaling it up or institutionalizing it, because each local authority (akinat) can stop such a development (“has the final saying”). Even a number of narcologists are still opposing OST. Many of them had been educated in Russia or according to Russian understanding of narcology. Some of them also fear to lose patients (who are now asking for detox i.e.). There is still a lack of ownership of the programme, which is often seen as ‘international/western intervention’ (from WHO, UNODC, CDC, Global Fund etc.). Another obstacle is that studies financed by foreign donors are not recognized as ‘national studies’ and results are not accepted, even if the methodology is following international standards. The University, as an educational institute, itself is not able to take the lead in this issue. Regarding HIV among opiate users – as a catalyzer of the implementation of OST treatment – it seems to be as if the official data of HIV prevalence is being estimated too low. 24,000 HIV positive people had been registered in 2015 and 26,000 in 2016, out of which 17,000 are suffering from AIDS. 16,000 are treated with antiretroviral medication; out of these are 4,600 drug users. Anyway, although HIV prevention measures as provision of Clean-Needle-Syringes are not working adequately as the number of clients at “Trusts Points” is low. The state programme “Healthy Lifestyle” is not focusing on groups at risk.
Alcohol with high mortality rates is an important topic on the political agenda. On regional basis Healthy Lifestyle Centres will be developed to strengthen prevention efforts. Heroin consumption (and trafficking) is declining whereas synthetic drugs (‘spice’) are on the rise. Another plan of the Ministry of Health is to abolish “Forced Treatment Centres”. The experience with compulsory detoxification and ‘education through isolation’ (up to 2 years) did not work and didn’t change the addictive habits. The relapse rates are very high. No psycho-social support had been offered so far, just short detoxification and isolation from the society. Most of the patients should be offered psycho-social support and psychotherapy “as usual”. It is expected that 20% of the patients of these centres may be socially deprived people who will not be reached by psychotherapy. The Kazakh experts are interested in an exchange of experiences with European models of treatment for ‘untreatable’ persons (such as in social-therapy centres for Chronical Multiple Impairments) (specialized dormitories). In Kazakhstan, there are 4 rehabilitation centres for drug dependents and that there exists a State Normative Act to open such centres and to close “forced treatment” centres. In Kazakhstan does not exist a comprehensive education of social workers nor of psychologists working in the field of addiction and the Kazakh partners appreciate the support in this issue by German experts such as the Frankfurt University of Applied Sciences. In Germany “Guidelines on Social Work in Drug Treatment” had been developed by the National Association of Social Workers in Addiction field. These guidelines are also available in Russian and will be used in the CADAP trainings.
Treatment in prisons: In total, as of 31 December 2013, there were 6,099 registered patients with addictions to psychoactive substances in institutions of the Department of Corrections of the Republic of Kazakhstan. There were 3,084 people in compulsory treatment for addiction to psychoactive substances, half of them had alcohol problems, the other half drug related problems.
The staffing level of psychiatrists and narcologists in correctional institutions was only 60.8%, and as compared to 2012 (63.8%) the staffing level had decreased. Not all institutions had psychiatrists or narcologists (Kyzylorda and Mangystau regions). In correctional institutions of West Kazakhstan region, positions of psychologists were not foreseen by the staff schedule.
Stakeholders think that methadone treatment and even NSP in prisons should be considered. However, this is currently not applied in prisons in Kazakhstan. Inmates are tested twice a year. According to the officials no HIV infections have been registered within the prison system. Many stakeholders suggest that prison staff could benefit from better basic understanding of drug related problems. Positive developments are the State policy on reducing the prison population and in general open amongst policy makers for alternatives to incarceration for non-violent drug related crimes.
In a meeting with the Deputy Chairman and the Head of Unit of Medical Provision of the Committee of Criminal and Executive System (Penitentiary), at the Ministry of Interior, the CADAP team asked about the current problems with drug addiction issues in prisons: where are the problems, what are the health issues in prison? How can CADAP have an impact? The Deputy Chairman of the Committee mentioned the previous cooperation with CADP in supporting ‘Atlantis’ centres in prisons. As well cooperation with Dutch experts on treatment of tuberculosis had been carried out. There is also cooperation with programmes of UNODC and other international organizations. Regarding the issue of drug dependent prisoners a close cooperation with the Ministry of Health is existing. The Committee is organizing trainings in this regard to prison staff. One important part to deal with such problems is the involvement of affected prisoners into information activities among prisoners. A treatment protocol does exist to deal with drug addicted prisoners, conducted in cooperation with the Ministry of Health and the Pavlodar Republican Narcological Centre. In the framework of the programme “Healthy Kazakhstan” medical doctors, nurses and psychologists in the prison system are trained. Prisoners have the right to get access to medical assistance. But it is difficult to find personnel because most of the prisons are in isolated rural areas.
Drug situation in the Kyrgyz republic
As in the other Central Asian countries data on drug use in Kyrgyzstan are scarce. However, they do allow some conclusions regarding the nature and extent of the problem and regarding trends, useful information for drug policy making. According to statistic data from the National Drug Addiction Centre of the Ministry of Health of Kyrgyz Republic, the number of registered people who use narcotic drugs and psychotropic substances is increasing every year. There are reports of a steady increase of injecting drug use, particularly heroin use, involving a growing addiction problem, increased numbers of overdoses and health risks of spreading infectious diseases (HIV, hepatitis and other diseases transmittable by injecting drugs). The estimates of the number of drug users vary, but the available data point in the direction of around 9,000 till 10,000 registered drug addicts of which 6,000 till 7,300 are injecting drug users. The evaluative information on the number of persons registered in drug addiction institutions of the Kyrgyz Republic health system concerning drug dependence of all kinds is provided only once a year, i.e. data for 2013 were available in February 2014. As of 01.01.2013, the number of registered drug dependent people was estimated to be 9,900, 7,297 of them injecting drug users.10-12% are women and a small group are teenagers. The majority is reported to use heroin. The estimated total number of problem users or drug dependents is clearly higher. National and UNODC experts refer to figures between 25,000 or 26,000. They plead for better quality monitoring to have a more reliable fact base for drug policy making. The largest concentration of drug users is noted in the cities of Bishkek and Osh due to the fact that they have become major transit and distribution units, through which a significant volume of drugs passes to the countries of the CIS and far abroad“. Traditionally, cannabis and ephedra are popular drugs. They are growing wild and can be found in many places in Kyrgyzstan. The population of Issyk-Kul, Jalal-Abad, Talas, Chuy and Naryn is known for producing marijuana and hashish from the wild cannabis, which are distributed both at the local and regional illegal market. Synthetic drugs seem also to be rather well available based on licit, freely available compounds.
Though there is general agreement that the use of these drugs, and in particular of cannabis and heroin is still the main problem, various experts point at rapid and major changes of the drugs market in Kyrgyzstan. Many stakeholders reported that New Psychoactive Substances (NPS) like Spice (a synthetic cannabinoid) and amphetamines and methamphetamine (‘Crystal Meth’)are appearing on the market. [10-12,25-27]
Drug use in prisons: About 5 per cent of inmates is registered as drug users. However, according to expert information the estimated number of people who inject drugs in prisons could well be up to 19 per cent of the total prison population. Prisons form a separate system, under a separate Ministry, including the health services available in prisons. The Ministry of Health is only moderately involved in health services in prison, through participation in a commission on health in prisons. Overall, however, there seems to be a good cooperation between the Ministry of Health/Republican Narcological Centre and the State Service for the Execution of Sentences regarding the treatment of drug addicted inmates. There is a plan to have prison health services in 2018 transferred to the MoH. The State Service for the Execution of Sentences is also working on assuring the continuity of care, particularly after release, e.g. for methadone patients. This opens also doors for a better cooperation between health and prison authorities, a basis for the development of a balanced approach. Despite the limited resources, the Kyrgyz prison system is quite well developed. Meaningful achievements have been made in recent years. Two prisons had been modernised with support of International donors, including special provisions to facilitate the implementation of special treatment facilities for drug addicted prisoners based on the Polish ‘Atlantis’ model. The yet realised Atlantis and Clean Zone treatment facilities for drug users in prisons are sustainable und funded by the State Service. HIV prevention measures such as syringe distribution and Opiate Substitution Therapy (OST) have been successful implemented. Methadone Treatment is currently available in 8 prisons with more than 400 clients involved.
Treatment of drug dependents in the Kyrgyz republic: 6,250 heroin users are registered in the narcology registers (Government of the Kyrgyz Republic, 2014). The main treatment options are:
- Detoxification (inpatient and outpatient, generally supported with methadone), which is available countrywide.
- OST, i.e. methadone maintenance treatment including psycho-social support. Currently 31 OST sides are reported working in Narcological Clinics and Family clinics and 2 in TB Centres and 8 in prison settings [22,23].
- Inpatient medical and psychological rehabilitation and outpatient rehabilitation programmes through 12-step systems in the Republican Addiction Centers and the Inter-regional Centre of Addiction in Osh.
- Motivational programmes for access to and continuation of treatment and the prevention of relapse and overdose on an outpatient basis.
- Treatment / rehabilitation in prisons include 8 rehabilitation centres ‘Atlantis’ targeting inmates addicted to alcohol and drugs and a so-called ‘clean zone’ of the Centre of Rehabilitation and Social Adaptation in the penal institution No. 31 of SPS. The latter has been realised with the assistance of CADAP 5 funded by European Union and “enables patients of Atlantis program, who have successfully completed the basic therapy, to continue their rehabilitation, gain and strengthen work skills, obtain primary vocational education and successfully complete the process of reintegration and adaptation in civil society after release”. (Government of the Kyrgyz Republic, 2014).
Treatment services are provided by State organisations and by NGO’s. AIDS Foundation East-West (AFEW), for instance, provides an opportunity to pass detoxification therapy and rehabilitation for people with opiate addiction on the basis of the three local NGOs (“Society” in Bishkek, “Parents Against Drugs” in Osh and “Ayan-delta” in Tokmok).
Challenges: Main challenges are the limited capacity and unsatisfactory quality of treatment, in particular regarding rehabilitation/drug-free treatment. There is just one rehabilitation department (with a capacity of 40 beds) for the whole country. Alsothe availability of OST, psychosocial interventions and (social) rehabilitation is judged as ‘moderate’ (Zabransky and Mravcik, 2013). Abstinence oriented treatment programmes are mainly focussed on detoxification, a limitation that does meet the treatment needs and required quality of services. The important role of NGOs in the implementation of treatment and rehabilitation is not recognised. Moreover, NGOs are divided.
Treatment in prisons: The penal system in Kyrgyzstan is administered by the State Service for the Execution of Punishment (SSEP). In 2002, control over service was transferred to the Ministry of Justice from the Ministry of Affairs, a transfer intended to improve transparency and allow local and international observers greater access to prison.
SSEP jurisdictionincludes33penalestablishments, including-11prisons for sentenced persons: one each is dedicated for women, male minors and members of the lawmen force men agencies
SEP is also responsible for 14 ‘settlement colonies’where in mates can leave during the day, provided they return at night. Finally, SSE oversees 6 pre-trial detention centres, including one for women. Prison security including control over check point, Satcolony entrances and the transportation of in mates to and from prisonsisoverseen by the department of protection and convoys, also subordinate to the Ministry of Justice. In 2013, there were 7,961 prisoners in the 11 prison facilities in Kyrgyzstan, including one facility for women. Women account for 4.0% of the prison population. Approximately 1,300 individuals are released from these facilities each year. The incarceration rate is 181 per 100,000 populations, exceeding the world average of 146/100,000, and the occupancy rate is 55.5%, which is a result of marked reductions in the numbers of prisoners over the past decade.
In the meeting with the Medical Unit of the State Service for the Execution of Sentences mid October 2015 it was discussed the “wish list” for investment support for the treatment centres in the prison system, such as ‘Clean Zone’ in prison Nr. 31 and for the Women Prison Nr. 2. The plan is to establish a ‘Clean Zone’ in the Women Prison to improve the sustainability of treatment in ‘Atlantis’ centre. The CADAP team is asking for concrete planning information and the cost-estimation of such building and equipment.
The CADAP team is impressed of the development in the Kyrgyz Republic to establish public health innovations in the prison system esp. to prevent the negative consequences of drug addiction. This is a good basis for further cooperation. At the WHO Regional Conference of ‘Health in prisons’ in Bishkek from 27 - 29 October 2015 these efforts had been acknowledged. The research conducted by the Yale University will deliver the scientific verification for the positive effects on the reduction of drug problems and infection diseases of the measures taken by the prison authorities.
Also the new reform of the transition of the responsibility for the prison health system away from the penitentiary system to the Ministry of Health is part of the de-militarization of the Kyrgyz prison system. This reform is part of the Drug Strategy 2017 – 2020. The reform is on the way now. 30 positions in the prison medical system will be integrated in the public health system.
Drug situation in Tajikistan
The Republic of Tajikistan is a presidential republic. The country has presidential and parliamentary elections on a regular basis. The capital is Dushanbe. The area is 142,970 square kilometres. The population size is 8.5 million inhabitants.
Tajikistan is located in the southeast of Central Asia. 93% of the territory is part of the mountainous system of Central Asia. The Republic of Tajikistan has borders with the following republics: in the south – with the Islamic Republic of Afghanistan (1,206 km), in the west and in the north – with the Republic of Uzbekistan (1,161 km) and the Kyrgyz Republic (870 km), in the east – with the People’s Republic of China (414 km). The total length of the state border is 3,651 km.
Tajikistan is not a major producer of narcotics. Tajikistan shares a border with Afghanistan, which produces nearly three-quarters of the world’s opium. As the gateway to the “northern route” of trafficking, Tajikistan is on the frontline of opiate trafficking from Afghanistan to the Russian Federation, Europe and increasingly to China. Although cultivation and potential opium production declined (officially) in Afghanistan in 2010, the opiate flows through Tajikistan continue to be worrisome. The opiates production in Afghanistan is a threat for stability and security in Tajikistan. Large stockpiles are believed to exist in northern Afghanistan along the borders with Tajikistan and Uzbekistan that enable drug traffickers to provide deliveries of opium and heroin across the Afghan border into and through Central Asian countries destined to Russia and West European countries. In addition to trafficking in illicit drugs, trafficking in chemical precursors is also becoming a growing regional concern. Transforming raw opium into heroin requires the early addition of chemical precursors. As Afghanistan does not produce these chemicals, large volumes of illicit precursors required for the conversion of opium are being smuggled in from other countries, including Tajikistan13.
The United Nations Office on Drugs and Crime (UNODC) estimates that annually about 25 percent of the heroin and 15 percent of the opium produced in Afghanistan is smuggled through Central Asia, with 85 percent of that amount passing through Tajikistan, totalling between 75 and 80 metric tons per year of heroin and between 30 and 35 metric tons of opium.
Studies to estimate the population of opiate users, including injecting drug users (PWIDs), were not carried out recently. According to research by the AIDS Project Management Group conducted using the Factor and Delphi methods in 2009, the number of injecting drug users in Tajikistan was estimated to be 25,000, with a possible range of 20,000–30,000 (AIDS Project Management Group, 2009).
Officially there are 7, 116 drug users in the narcological register in Tajikistan in 2013. In 2014: 7,279; in 2015: 7, 313.
According to government statistics the overall drug situation is apparently gradually stabilising. In 2011-2013 there was a decline in the number of registered people with addiction (in dispensary registration) [28-41]
Drug use in prisons: From 2005 to 2009 the number of HIV infection cases among prisoners in 2 cities (Dushanbe and Khujand) increased from 6.2% to 8.6%. Experts believe that sharing injecting equipment and availability of drugs contributed significantly to the HIV epidemic in prisons in Tajikistan.15
There are no reliable figures about addiction problems in prisons. Indications are the cumulative numbers of HIV positive prisoners, who were detected in penitentiary facilities: 2010: 219, 2013: 234, 2014: 620. Another indication is the number of people in prison convicted to forced [42].
Treatment of drug dependents in tajikistan: The treatment of drug dependents in Tajikistan is carried out in specialised drug treatment facilities. The state guarantees anonymity of voluntary treatment. Social integration services are provided by some non-governmental organisations.
Capacity of treatment and rehabilitation of drug dependents in 7 treatment centres with 320 beds.
Services offered in drug treatment:
- Inpatient treatment (detox)
- Short-term rehabilitation measures
- Outpatient relapse prevention
- Medical-social rehabilitation
- Opioid substitution therapy16
In 2011 a total of 1,207 people received inpatient treatment in substance abuse treatment centers. Of these, 80.7% received a diagnosis of heroin addiction. The number of drug users who received hospital treatment in 2011 increased by 200 (19.86 %) compared to 2010, but decreased again in 2012 by 30417
In 2010 the pilot program of opioid substitution therapy (OST) was launched in the Republic of Tajikistan, in order to prevent the further spread of HIV infection and disease, with the financial support of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and other donor organisations. OST is now provided in 6 sites for 638 clients (data from 2015). 2 new sites are planned in prisons. By the end of 2017, 12 OST sites are planned in the country [25].
New guidelines for OST have been developed for civil medical services and penitentiary settings.
The “single window” approach is implemented in one of OST centers (OST/ HIV/ TB), the implementation in other centers is ongoing.
In meetings with the Chief Narcologists and other experts during the Assessment Mission (5-6 October 2015) it was mentioned that the services in the country meets all international standards for treatment of drug dependents and as for harm reduction.In the treatment centres also an integrated treatment for HIV/TB will be integrated (‘single window’ approach). In 46 (trust) points, Needle-Exchange-Programmes are implemented which had a positive impact on the reduction of infection diseases. The HIV prevalence among injecting drug users had been reduced from 55% to 29% (Table 3).
Treatment in prisons: In the Republic of Tajikistan, with a population of 8.5 million inhabitants, the prison population consists of approximately 10,000 inmates in 19 prisons. The number of HIV patients detected in prison system is increasing (from 25 in 2003 to 620 in 2014). In 2014 there were 394 people with addiction in correctional institutions upon court order.
The treatment of people with addiction is carried out in medical units of correctional institutions based upon court order of compulsory treatment due to drug addiction.
In case there is no court order and there is indication of drug addiction the medical staff has to invite a narcologist from a narcological service of the MoHSP. If the diagnosis is set, the person will receive treatment.
Treatment consists mainly of detoxification. Furthermore, the following therapeutical methods are used: vitamin therapy, glucose injections, intravenous infusions of physiological solution, and individual sessions ofpsychotherapy.In the meeting with the staff of the prison administration the challenges of HIV-infections and substance use control was discussed. The Tajik partners explained that they want to continue the good cooperation with CADAP as they are also cooperate with other international partners, such as UNODC. Opioid substitution treatment: In 2006 the discussion about OST in penitentiary system started. Management and staff from the prison system participated in several study visits to European countries and to Iran to become familiar with OST implementation in penitentiary system, several trainings on OST were organised for penitentiary system staff.
Drug situation in Uzbekistan
Uzbekistan is a presidential republic in Central Asia. The country has presidential and parliamentary elections on a regular basis. The total area of Uzbekistan is 447,400 square kilometres. Uzbekistan has borders with Kazakhstan, Turkmenistan, Kyrgyzstan, Tajikistan and Afghanistan. The length of borders of Uzbekistan is 6,621 km. Uzbekistan exports cotton, gold, uranium ore, natural gas, mineral fertilizers, metals, products of textile and food industry, cars. The population of Uzbekistan as of 1 January 2014 consists of 30,492,800 people. In Uzbekistan in 2010-2013 there was a high birth-rate and positive population growth18
No general survey to evaluate the prevalence of drug use among the general population has ever been conducted in the Republic of Uzbekistan. In 2006, with the support from the United Nations Office for Drugs and Crime (UNODC) Uzbekistan conducted a survey, which was based on the methods developed by the European School Survey Project on Alcohol and Drugs (ESPAD), to evaluate the use of alcohol, tobacco and drugs among the pupils of 9th forms in the comprehensive schools. According to this study the number of people, who have used drugs (cannabis and inhalants) 1-2 times in their life time, was 0.5%19
In 2006, under the aegis of the UNODC, another survey was conducted in Uzbekistan to evaluate the prevalence of problem drug use. According to the information collected during the survey, the number of problematic injecting drug users (IDUs) could reach the figure of 80,000 adults20
According to more recent estimations performed by the Republican AIDS centre, the number of drug users has been reduced to 49,000 in 201121
The drug situation in the country has ‘stabilized’: Reduction of the incidence of drug use from 9,8 to 2,9%; reduction of opiate users among drug users from 83 to 60,3%; Heroin use reduction from 67,7 to 49,6%; injecting substances is going down from 46,4 to 28,9%; drug related deaths is reduced from 191 to 7% and HIV prevalence is going down from 59,4 to 6,2%22 [43-47] .
Drug use in prisons: There were about 46,200 prisoners in Uzbekistan in 2013, which is 4,000 more than in 2009. According to the data from the Government of the Republic of Uzbekistan, the number of prisoners dropped by 50% in the period from 2000 to 2012. Recent estimate is that about 20% is in prison because of drug related crimes. Officials state that there are no drugs used in prisons23.
Treatment of drug dependents in uzbekistan: Uzbekistan has a comprehensive system of narcological assistance to people with drug addiction. Assistance is provided upon their request or with their consent, and to young people up to 14 years upon request or with consent of their parents or other legal representatives. Anonymity of treatment is guaranteed to people with drug addiction and toxicomania who have referred themselves to narcological institutions for a course of treatment upon their request.
“Narcological assistance” includes examination, counselling, diagnostics, and treatment, medical and social rehabilitation. These types of assistance to people with drug addiction are provided in licensed institutions of state and private healthcare systems.
There are in total 1,783 beds in the country for treatment of narcological patients. Narcological assistance is also provided in 18 private clinics that have a license for such services.
Narcological institutions in Uzbekistan are implementing a new model of narcological assistance based on a holistic approach to the needs of PWUD for medical, psychological, and social services. This model ensures quality and effectiveness of health care interventions and expands access of PWUD to treatment and rehabilitation programmes.
Statistics show a decrease in the number of registered drug users: in 2012: 17,235; in 2013: 16,045; in 2014: 14,692. In 2015: 13,218 out of which 60.3% was for opiate addiction24. In 2012, 3,727 (in 2013:2,936) patients were treated in rehabilitation facilities (inpatient drug treatment units), with 91.6 percent of those seeking treatment for opium addiction. Over 69 percent of patients received treatment in in-patient facilities and 26.3 percent in out-patient facilities.
A pilot OST programme was opened in Uzbekistan in 2006. OST was provided with the use of methadone and buprenorphine. In 2007 WHO experts evaluated this pilot project and noted some parameters that demonstrated positive trends for patients after the start of treatment such as refusal from illegal drugs, improvement of general health, decrease of criminal activities. After evaluation, recommendations were given to expand accessibility of OST in Uzbekistan through opening similar projects in different regions of the country. In 2008 the Ministry of Health conducted its own evaluation of the pilot OST project. The results were presented at a Commission’s meeting with participation of international and state organisations and NGOs active in the sphere of HIV and drug prevention. In 2009 the Government of the Re-public of Uzbekistan decided not to prolong the OST programme, referring to its ineffectiveness. Recently, the debate has been reopened. Experts from the AIDS centre expressed the opinion that OST might be a valuable part of improvement of HIV prevention and of sustaining the progress in HIV reduction.Regarding OST, the National AIDS Centre as main recipient of Global Fund financing, has been asked to conduct a feasibility study on the implementation of a (new) OST programme in the country as part of the ‘Harm Reduction’ strategy25 [23].
Drug Situation in Turkmenistan
Turkmenistan is located in the south western part of the region in an area of deserts, between the Caspian Sea in the west and the Amu Darya river in the east. Turkmenistan borders in the north with the Republic of Kazakhstan, in the north-east and in the east with the Republic of Uzbekistan, in the south-east – with Afghanistan, in the south – with the Islamic Republic of Iran, in the west the border runs through the Caspian Sea. The area of Turkmenistan is 491.21 thousand square kilometers. The length from north to south is 650 km, from west to east – 1 100 km. The population of Turkmenistan consisted in 2013 of 5,240,000 people.
Turkmenistan is a trans shipment route for narcotics trafficked from Afghanistan to Turkish, Russian, and European markets, either directly or through Iran. However, it is not a major producer or source country for illegal drugs or precursor chemicals.
Officials state that drug use is declining or even has been eradicated in Turkmenistan26. However, other information indicates otherwise: these unofficial sources refer to “a catastrophic drug use situation in the country that also becomes even more serious”27.
It is difficult to assess the real situation, because reliable figures on the current situation are not available. The latest official data are collected in the UNODC/Paris Pact report of February 201528. However, unofficial reports suggest seizures of significant volumes of drugs occur frequently and may not be reflected in official reports. There is no evidence of synthetic drug production in Turkmenistan, and the Government of Turkmenistan reported no seizures of synthetic drugs.
According to national experts, thanks to successful (relapse) prevention programmes, there are no (longer) serious drug problems in the country. In-official reports and the UNODC World Drug Report indicate a number of drug users between 32 000 up to 100 000.
Tobacco smoking could also be reduced significantly up to an internationally extraordinary low level in the population thanks to successful measures of tobacco policy (banning advertising, no production of tobacco, sales only in state-own magazines, no smoking in public etc.)29.
he Turkmen experts expressed their interest in EU expertise on psychotherapy, including methods such as hypnose or Gestalttherapie, and knowledge on early detection, prevention and treatment on New Psychoactive Substances‘(NPS). Furthermore Peer Support work could be a subject of knowledge transfer30. Problem with the assessment of the effectiveness of the Treatment system is that the Government of Turkmenistan has not published any drug use related statistics since 200631.
OST is not available In Turkmenistan. Nevertheless, there are no legal barriers to implement OST programmes in the country [48-51].
Drug use in prison: Turkmenistan has 22 correctional institutions, 12 of them are prison colonies with various regimes, 6 remand centres, 2 treatment and labour facilities, 1 in-patient hospital for prisoners, and 1 disciplinary battalion for soldiers. Every police station also has a centre for temporary isolation, a total of 53. Colonies and prisons in the country (excluding the disciplinary battalion) can contain up to 8,100 prisoners. 26,720 people were incarcerated in 200932.
In Turkmenistan correctional institutions are subordinated to the Ministry of Internal Affairs. People sentenced for medium severity drug-related crimes mainly serve their sentences in general security colonies. According to the statistical data from the Expert Group on Turkmenistan, in 2006 in correctional institutions there were 2,999 cases of drug addiction registered. According to the data from national experts33 , the proportion of people serving sentences for drug-related crimes in 2007 was 19%: in general security colonies serve their sentences 3.12% of people, in strict security colonies – 9.41%, in prisons – 4.2%, in colonies with a special security – 2.27%. According to the Expert Group on Turkmenistan, there are allegedly no narcotics in any of the correctional institutions34. Several international organisations have tried to get access to prisons, but with limited success, no reliable data are available on population in prisons and offenses committed, nevertheless “health” is considered a good topic to start discussions in these settings35.
Treatment of drug dependents in turkmenistan: The Ministry of Health operates six drug treatment clinics, one out-patient facility for drug dependents in Ashgabat, a Psychiatric and Narcological Hospital in the Ilyaly district of Dashoguz province, and a Psychiatric and Narcological Hospital in each of the other four provincial administrative centers. There are some specialised treatment facilities for people with drug addiction that are subordinate to the Ministry of Internal Affairs. Substance users can receive free detoxification treatment at these clinics without revealing their identity, as clinic visits are kept confidential36.
In 2015 a brand-new rehabilitation centre became operational using all modern methods of treatment37.
Table 1: Opiate Substitution Treatment (OST) in Central Asia (CDC Almaty).
| County | # of OST Sites | Year of Imolementation | OST Patients | Estimated number of IDU | % of coverege with OST |
| Tajikistan | 3 | 2010 | 200 | 25000 (2009) | 0.8 |
| Kazakhstan | 10 | 2008 | 460 | 125,00 (2011) | 0.4 |
| Kyrgyzstan | 26 | 2002 | 1,600 | 26,000 (2004) | 6.1 |
Table 2: Registered drug users, treatment demand in Kazakhstan1 , 2
| 2010 | 2011 | 2012 | 2013 | 2014 | |
| Number of drug dependents diagnosed for the first time | 7,233 | 6,145 | 5,062 | 5,624 | n/a |
| Rate(100,000) | 45 | 38 | 31 | 34 | n/a |
| Opioid users (%) | 41.0 | 31.1 | 28.8 | 28.5 | n/a |
| Cannabioid users (%) | 48.0 | 58.0 | 60.5 | 60.2 | n/a |
| Polydrugusers(%)25 | 8.2 | 8.6 | 8.5 | 9.3 | n/a |
| PWIDs(%) | 41 | 37 | 63 | 50 | n/a |
| Total number of registered people who use drugs | 47,756 | 44,825 | 39,291 | 38,203 | 33,847 |
1 UNODC/Paris Pact, 2015
2 It must be noticed that the tables above, originating from the UNODC/Paris pact report 2015, show (slightly) different figures than other sources, like the Regional Report on the Drug Situation in Central Asia, MCAD, and the data from the General Prosecutor’s Office of Kazakhstan, January 2016, but we limit ourselves here in the framework of this policy assessment report to drawing this general, global picture.
Table 3: Registered drug users, treatment demand in Tajikistan6,7
| Drug users recorded indispensaries3. | |||||
| 2010 | 2011 | 2012 | 2013 | 2014 | |
| Total number | 7,398 | 7,117 | 7,231 | 7,176 | 7,279 |
| Rate(100,000) | 97 | 91 | 90 | 87 | 87 |
| Opiate users (%) | 90 | 92 | 91 | 90 | 91 |
| Drug users recorded indispensaries | |||||
| 2010 | 2011 | 2012 | 2013 | 20144 | |
| Heroin users (%) | 75 | 81 | 81 | 81 | 80.8 |
| Cannabinoid users (%) | 5.5 | 4 | 4 | 4 | 3.7 |
| Poly drugs users (%) | 6 | 5 | 5 | 5 | 5.1 |
| MD MA users (%) | 0 | 0 | 0.01 | 0.01 | |
| Injecting drug users (%) | 62 | 59 | 63 | 67 | 64.7 |
| Drug users registered for the first time | - | 727 | 685 | 674 | 606 |
| Source: Republican Narcology Center of the Ministry of Health and Drug Control Agency of the Republic of Tajikistan | |||||
| Drug treatment5 | |||||
| 2008 | 2009 | 2010 | 2011 | 2012 | |
| Treated drug dependent users | 1,152 | 1,286 | 1,007 | 1,207 | 902 |
| Heroin users (%) | 84.2 | 80.8 | 87.7 | 92.5 | n/a |
| Opium users (%) | 4.1 | 9.3 | 12.1 | 4.0 | n/a |
| Hashish users (%) | 0.1 | 0.5 | 0.2 | 0.1 | n/a |
| Poly drugs users (%) | 11.6 | 9.5 | 0 | 3.5 | n/a |
| Treated for the first time (%) | n/a | n/a | n/a | n/a | 75.9 |
| Drug overdoses | 15 | 15 | 16 | 19 | n/a |
| Source: Ministry of Health, CARICC, CADAP Country reports | |||||
1 Central Asia Human Development Report: Bringing Down Barriers (http://europeandcis.undp.org/governance/hrj/show/300BDC00-F203-1EE9-BE944F24EDFC0
2 The world health report 2008: primary health care now more than ever. (http:// www.who.int/whr/2008/en/index.html)
3 The strategic plan for development of the Republic of Kazakhstan until the year 2020
4 Problem is that most of the synthetic drugs were not covered by legislation (and thus not seized and registered) until three years ago
5 Information provided by General Prosecutors Office, Jan 2016. As in the other Central Asian countries reliable and up-to-date data on drug use in Kazakhstan are scarce, however there are some valuable sources of information (Zabransky and Mravcik:The Regional Report on the Drug Situation in Central Asia, 2013; OSCE, 2014; EMCDDA, 2014; UNODC/Paris Pact, 2015, Pompidou Group Country profile Kazachstan 2014, reports of the Monitoring Centre for Alcohol and Drugs in Kazakhstan (MCAD).
Officials estimate that unregistered drug use and addiction might still be twice as high as the officially published estimates, and are concerned that Afghan instability may contribute to a sharp increase in the near future. Almost all stakeholders confirm this.
6 TheRegional Report on the Drug Situation in Central Asia, 2013
7 Website MCAD: http://MCADkz.org/en/index.html
8 According to MCAD one of the reasons may be that the methodology of survey was changed almost every two years (in sampling and methods of estimation)
9 Pompidou Group, Country profile Kazakhstan, 2014
10 Approx. 7% of inmates are drug dependent users (2,380 out of 34,000). From: I I Michels, CADAP mission report 25-29 Jan 2016
11 The Regional Report on the Drug Situation in Central Asia, 2013
12 Although even the Prosecutors Office takes a ”neutral” position in this discussion
13 Dublin Group 2013
14 Pompidou Group country profile Tajikistan 2014, EMCDDA country overview Tajikistan 2014
15 Pompidou Group country profile Tajikistan 2014
16 Presentation National Center for Monitoring and Prevention of Drug Use, MoHSP 2016
17 EMCDDA country overview Tajikistan 2014
18 Pompidou group, 2014, Alex Chingin and Olga Fedorova, Country profile Uzbekistan
19 Zabranskya.o. The Regional Report on the Drug Situation in Central Asia, 2013
20 Pompidou group, 2014, Alex Chingin and Olga Fedorova, Country profile Uzbekistan, EMCDDA: 2014
21 Rep. Aids Centre,
22 Andrey Mokry from the National Committee on Drug Control at the CADAP Assessment Mission on 17th May 2016
23 Pompidou group, 2014, Alex Chingin and Olga Fedorova, Country profile Uzbekistan, EMCDDA: 2014, Mission Report Uzbekistan May 2016
24 Zabranskya.o. The Regional Report on the Drug Situation in Central Asia, 2013, Mission Report Uzbekistan May 2016, UNODC/Paris Pact 2015
25 Mission Report Uzbekistan May 2016
26 CADAP mission report to Turkmenistan, H. Stoever and I. Michels, 4-8 April 2016
27 Dublin Group 2015
28 UNODC /Paris Pact 2015
29 However also here reliable data are scarce
30 CADAP mission report to Turkmenistan, H. Stoever and I. Michels, 4-8 April 2016
31 US State department, Bureau of International Narcotics and Law Enforcement Affairs, 2015 Report Turkmenistan
32 More recent data, especially the rate of imprisonment of the last years: http:// www.prisonstudies.org/country/turkmenistan
33 Pompidou group, 2014, Alex Chingin and Olga Fedorova, Country profile Turkmenistan
34 Pompidou group, 2014, Alex Chingin and Olga Fedorova, Country profile Turkmenistan
35 CADAP mission report to Turkmenistan, H. Stoever and I. Michels, 4-8 April 2016
DISCUSSION AND CONCLUSION
Challenges
Need for innovation: As previously mentioned the number of clients in treatment is decreasing, however it is not clear whether the number of people in Central Asia with drug related problems is decreasing as well. An explanation could be that the treatment offer does not meet the requirements of modern society, that there is a need for developing a more comprehensive treatment offer, more tailored to the needs of clients, for instance drug users with comorbidity. The narcology centres are acknowledging this need and are stimulating and supporting this process of innovation, however with limited means.
Collaboration and more flexibility: Many stakeholders indicate that the collaboration between different services providers, especially if they are administered by different authorities, needs improvement. Quote: “on paper the collaboration is excellent, in practice it is not”. The system has to become more flexible, with the treatment needs of the patient as the starting point, instead of the treatment offer (the example was mentioned of a drug addict, with mental disorders, who is on methadone prescription, also suffering from TB: who is responsible?). General problem here seems to be the culture in the Kazakh administrative system of “vertical communication” instead of “horizontal communication “between service providers (everything has to be approved by the top management of the different sectors before any cooperation can be realized). In these issues there is no final responsibility in the structure: Ministries, Oblasts, narcologists, prosecutors, they all have their own position and responsibilities, without any common, comprehensive leadership or guiding principles.
Modernizing the registration system: Many stakeholders point at the fact that the registration of drug dependents in the treatment system is a major obstacle for many potential clients. This Narcological Register is a heritage of the former Soviet system and its main objective was to keep clients under control, for public safety reasons rather than for treatment purposes. In practice, being registered still has far-reaching consequences, like denying access to posts in the school system, law enforcement, military and state services in general, and refusing a driver’s licence or firearms licence; a person that is registered in the narcological register is not eligible. People are kept within this registration for five years after completion of the treatment. Understandably, many clients do not want to be taken into this register, and accept that as a consequence they cannot be treated38.
Another aspect of the registration system: It is the need to modernize this in order to allow patients to move more easily from one service provider to another, or making use of more than one provider at the same time. The narcology centres are currently working on a more flexible registration system.
Compulsory treatment, often on basis of a court decision, is applied in almost all oblasts; the clients stay in clinics for two years. In many cases after detoxification no follow-up support is given to them, they just have to do some simple work. As one stakeholder mentioned: “this is in fact forced labour”. As a result, relapse rates are very high. Authorities are aware of this and are looking for alternatives. The Central Asia experts are interested in exchange of experiences with European models of treatment for ‘untreatable’ persons39.
Rehabilitation: This area also requires innovation. There are some positive initiatives, like the efforts to work more closely together with employment agencies (“Social Lift”). Also social workers need more support and expertise (there are more than 2000 sw’s in the country).
Quite a number of other concrete challenges: have been mentioned during assessment missions: the lack of outpatient treatment options, lack of quality assurance, stigma’s in the health sector, lack of services in prisons, insufficient capacity to diagnose and treat co-morbidities. In order to stimulate the need for innovation expert input from among others the EU could be considered regarding treatment of users of the ‘new’ substances mentioned above (NPS, etc.), but also regarding specific elements of the treatment of heroin dependents. This could be done by a study visit of key decision makers and experts to EU Member States. Development of guidelines and standards for the different types of treatment. Systematic training of treatment staff (with official certification, following the model of Pavlodar Republican Centre of Narcology).Support and Research budgets: innovation and flexibility could be stimulated for example by the creation of an Innovation Fund. However, in order to achieve this, researchers and experts should collaborate better in formulating their needs. The focus should be on developing more patient-cantered treatment offers.
36 US State department, Bureau of International Narcotics and Law Enforcement Affairs, 2015 Report Turkmenistan
37 CADAP mission report to Turkmenistan, H. Stoever and I. Michels, 4-8 April 2016
38 Those who are treated by private clinics (not covered by state funding) are not taken into the narcological registers. See for more information about the narcological registration: http://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-016-0093-2.
39 I. Michels, CADAP Mission report 25-29 Jan 2016, Mission report, http://www. icnl.org/research/monitor/kazakhstan.html
ACKNOWLEDGEMENTS
Ingo Ilja Michels developed the draft for this article, based on Bob Keizer`s Assessment reports on the state of play of drug policy making in Kazakhstan, Kyrgyzstan, Uzbekistan, Tajikistan and Turkmenistan (Amsterdam December 2016) and his own Assessment Reports. Franz Trautmann died shortly after the Assessment Mission to Turkmenistan in June 2016.The other authors HS, ER, collaborated equally with drafting and finalizing the paper. All the authors read and approved the final manuscript. The article is dedicated to Franz Trautmann.
