Controversial methadone therapy may become nationwide in Kazakhstan by 2016

Kazakhstan may approve a full scale state methadone program by 2016, Tengrinews reports from a Central Communications Services briefing in Astana.

"Our country approaches this therapy very carefully. Two expert evaluations of the therapy have been made and the latest one conducted by international experts from Columbia University in 2012 showed the same positive results that were observed in the course of implementation of this program in our country. Thus, we are planning to make the program a nationwide one in 2016. The efficiency of opioid substitution program for a select number of individuals has already become evident and there is a need for it on a wider scale,” Altynay Yeskaliyeva, head of the National Scientific and Practical Center on Medical and Social Problems of Drug Abuse, declared on August 20.

Yeskaliyeva further assured that the program would be inexpensive: "This is a cost effective method since the daily costs of treating an addict with the substitution therapy makes one dollar. One dose of methadone per patient would cost the government a mere 180 tenge ($1), meaning that the monthly cost is to be no more than six and a half thousand tenge ($30). Compare this to the cost of an average daily dose (of heroin) a drug addicts consumes – two and a half to three thousand tenge (around $15), or the cost of rehabilitation treatment - more than 100,000 a month ($550)."

The Center also claimed the cost of the treatment could be decreased even further if production of methadone is established in Kazakhstan. 

The doctors insist that participation in the program significantly reduces the patients’ expenditures on psychoactive substances not prescribed by doctors. Currently these may cost a patient 229,403 tenge ($1260) monthly.

Opioid substitution therapy (OST) has been brought back on the agenda this summer, when the National Scientific and Practical Center on Medical and Social Problems of Drug Abuse stood up in favor of the full scale government program. The acting head of the psychotherapy and rehabilitation department of the Center Madi Tokanov said he was sure that Kazakhstan needed the methadone therapy.

He became especially convinced after an international conference on HIV/AIDS that took place in Astana this summer. “Representatives from Iran, Kyrgyzstan, Tajikistan, Ukraine, Afghanistan, and Kazakhstan were attended it. They spoke positively about OST. The program has established itself in good light,” Tokanov said.

However, he admitted that the issue of introducing a state OST program in Kazakhstan had not been yet decided upon.

The pilot program that has been in place in Kazakhstan since 2008 is fully sponsored by the Global Fund, meaning that no state money is involved. The number of patients receiving treatment is about 200 people. Should a state program be introduced, one can imagine this number increasing to thousands. According to official numbers, there are about 38,000 drug addicts in the country (the unofficial number is five times greater).

Tokanov noted, however, that OST did not envisage 100% coverage of all the drug addicts. “The program is intended solely for the patients with severe addiction, who had unsuccessful attempts to undergo medical treatment and rehabilitation, detoxification; who lead an antisocial lifestyle. The replacement therapy is meant for this kinds of patients,” he said.

According to Tokanov, methadone is now undergoing a registration in Kazakhstan, which is expected to be completed by the end of the year. The drug can be obtained only from a narcologist, who prescribes this treatment if all others fail. The therapy is carried out under the supervision of a team of several doctors, including a psychologist.

The doctor also said that the pilot project has borne successful results in Kazakhstan. According to him, 2 women, who underwent OST, gave birth to healthy children. Other 32 patients started families, 20 pursued education - they had a quality remission, 167 got employed, 32 patients began receiving treatment for HIV-infected, and 102 patients completed the program after reducing their dosages. All of the participants of the program said that they stopped thinking about finding drugs and their family relations had improved.

Currently, the project runs in 10 cities of Kazakhstan: Pavlodar, Ekibastuz, Karaganda, Temirtau, Taraz, Kostanay, Aktobe, Uralsk, Semey and Ust-Kamenogorsk. As of June 1, 2014, the project involved 192 people. Of them, 144 were men and 48 were women. 117 were formally employed. There were 53 HIV-positive among the patients.

As for the widespread conviction about the side effects of the program, in particular irritability and aggression, the doctor noted that it was a common occurrence during withdrawal periods for all drug addicts. In addition, he denied all the rumors about methadone overdoses and said that they found no confirmations to such claims.

"Opponents of the replacement therapy said that about 100,000 physicians spoke up against this method of treatment, they wrote letters asking why the project was being implemented. We have tried answering these letters, we wrote and sent a letter to one of the address indicated on the letters, but it turned out that these people did not exist, it was all invented, and the addresses were invented. We really do not understand what was the purpose of all this," Tokanov said.

The doctor claimed that he personally had seen the positive effects of the treatment and that OST was recommended by WHO and a majority of experts in the world.

"Previously, our opponents said that the United States was lobbying [for distribution of methadone] – to this I say unequivocal “no”. The experts from Iran showed a presentation, where they said that 100,000 people were undergoing OST there and that it was successful," he said.

In fact, the American government has been assisting Kazakhstan in fighting drug abuse and funded various projects to achieve the goal. Most of them were welcome.

Some in Kazakhstan claimed that there was active lobbying for expanding methadone therapy in Kazakhstan. The question whether this was true remains.

Methadone therapy started as a pilot project in Kazakhstan in 2008. Back then, two cities chosen for the project were Pavlodar and Temirtau. Stopping the spread of HIV and AIDS were named the chief goal of the project. By 2013, the program involved 273 patients and 10 cities.

Nevertheless, in August the same year, the Kazakh Health Ministry declared that it would not expand the program to cover more patients. A natural question arose: why would one curb a program that had proved to be successful?

Two Kazakhstan’s neighbors - Russia and Uzbekistan – had refused to use OST. They cited longer withdrawal period of methadone in comparison to heroin and the concept of the treatment itself – substituting one drug for another was not an answer to the problem, they said.

It emerged later that the desire to limit OST in Kazakhstan was not met without opposition from the U.S. government. One leaked letter was responsible for shedding light on this.

The letter in question was sent in 2011 and signed by former U.S. Ambassador to Kazakhstan Richard Hoagland. A copy of this letter was sent to Tengrinews editorial office by the Head of the Civil Commission for Human Rights group Natalya Shadrina.

The sentences in the last paragraph are of particular interest: “I strongly urge you to expand medication assisted therapy activities. Reversal of the initial decision to scale-up medication assisted therapy activities in Kazakhstan will have considerable public health consequences for the citizens of Kazakhstan and will endanger the approval of any future grants from the Global Fund…”

Commenting on the letter, President of the National Medical Association Aizhan Sadykova said that the United States were pushing Kazakhstan to continue the methadone program. However, Minister Kairbekova, to whom the letter was addressed, denied she had been blackmailed by the U.S. Ambassador.

The U.S. embassy also denied the allegations and said that the word “methadone” was not used in the letter.

Aizhan Sadykova, however, stood firm on her position that the US was pressing Kazakhstan to continue methodone therapy. “The US sponsored methadone promotion plan involves creation of methadone distribution points in every rehab and hospital, in NGOs, AIDS centers, TBC dispensaries and jails by 2014,” she said. She also noted that the National Medical Association started talking about closing the pilot project of methadone promotion in 2011, the same year the letter was sent.

“The Global Fund’s OST program will finish in 2014. After that our country will have to buy this drug at its own expense. The calculations raise some concerns as well. Kazakhstan spends $5 per day per one methadone user, while the neighboring Kyrgyzstan spends only $1,” she said.

“Back then it was discovered that methadone is promoted in violation of the country's legislation, as according to the International Convention, it is banned from use for medical purposes. Despite that, the pilot project on implementation of methadone as the opioid substitution therapy was launched. The decree on expanding the OST program was issued in 2010,” Sadykova said.

"There was a case when methadone was not delivered on time to Temirtau town (near Karaganda), and the aggression of the addicts was so dramatic that doctors barely managed to keep the situation under control,” Sadykova said.

The announcement made at the August briefing, however, showed that the Kazakh Ministry of Healthcare had not changed its mind, much to Sadykova’s disappointment. “We consider that OST is acceptable as one of the methods to treat drug addiction,” the Ministry once again stated.
 
Reporting by Renat Tashkinbayev, writing by Dinara Urazova