Like ‘Just Say No,’ but With More Kalashnikovs

LUHANSK, Ukraine — Miles of recently dug trenches mar the frozen landscape of the Donbass region in eastern Ukraine, signs of the ongoing war here between separatists and Ukrainian government forces. Farm fields are torn up; on some strategic highways, bunkers surrounded by tank tracks and mortar holes stand as high as houses. Travelers passing through half-destroyed towns can occasionally glimpse gangs of ragtag workers, digging and hauling sandbags under armed guard.

Last July, one of those workers was Ruslan, 33, from Horlivka. After the militants who had taken over his town seized him outside his house, he spent 21 days on the front lines, he said, “digging holes like a dog, and living in them like a dog.”

“They did whatever they wanted with me,” he said. “I can’t tell you how horrible it was.” The militants beat him up and shot at him several times a day. But that wasn’t the worst, he said. “It wasn’t even so much the physical treatment but the constant humiliation. ‘Junkie this, junkie that.’”

Ruslan is a drug user. He first injected homemade opium at age 12, and could not quit despite multiple stints in rehab. He’s lost most of his teeth as a result of abusing the popular street drug “krokodil,” but retains an irrepressible smile. Over the past few years, he has taken steps toward recovery since starting on a harm-reduction program in 2010 that includes substitution therapy (ST), whereby he receives the replacement substance methadone under close medical supervision. But for Ruslan, and many others addicted to drugs, life in the breakaway republics of eastern Ukraine has taken a dark turn.

The “Luhansk People’s Republic” (LNR) and “Donetsk People’s Republic” (DNR) regimes that have taken over this region have instigated a brutal war on drugs and alcohol, conducted through extrajudicial detentions, forced labor, and, allegedly, executions.

“It’s their policy to ill-treat drug users,” said Ruslan. His story of digging trenches is typical among drug users since the DNR and LNR took over; so is his assertion that one of his friends was shot by DNR militants after stealing to buy drugs. These new policies have driven back underground drug users who once received assistance such as clean needles and ST, and it is threatening to undo the recent gains made against addiction and HIV in one of the most drug-ridden regions of Ukraine.

Ukraine’s first war on drugs began in the early 1990s, after illegal drugs like homemade opium spread social disaster through the eastern and southern parts of the country, where poverty and unemployment were already rife. Draconian drug laws, which punished possession of small amounts with serious sentences, drove users into prison or away from any health and social services. As a result, the rate of HIV spread through intravenous drug use skyrocketed.

Later that decade, Ukraine changed its approach. International donors began to fund harm-reduction programs, which encourage safer drug use and better access to health care as a way of primarily preventing HIV transmission. Substitution therapy was introduced in 2006, and activists lobbied for reduced sentences and a more humane attitude to those addicted to drugs.

Ukraine is generally considered a harm-reduction success story. HIV cases among people who inject drugs have fallen, especially among users under 21, where the prevalence of HIV cases fell from 20 percent in 2007 to 5 percent in 2013. By March of 2014, there were around 8,000 ST patients throughout the country — many able to hold down jobs, improve their health, and take care of their families. Ruslan is one of them. By the time he started ST, “I smelled of the grave,” he said. “I stayed alive thanks to the program.”

Now the leadership of the LNR and DNR have reverted to a heavy handed approach on drug use and endemic alcoholism, which they say has been successful. In his office in the city administration building in central Luhansk, Vasiliy Nikitin, the LNR’s vice prime minister for social policy, said illegal drug use in Luhansk had fallen 10-fold since the militants took measures against drug trafficking.

“It was easy; we did it with law enforcement agencies,” he said. “We just got rid of corruption and the problem solved itself.” When I asked for further details, he cut the interview short. Downstairs in the lobby, a militant who called himself “Akim” assured me that soon the republic would be “free of alcoholism and drug addiction. Our laws on that will be very strict.”

According to interviews with local health and social workers and drug users, street drugs did indeed disappear during the summer of 2014, as Ukrainian law enforcement in the region dissolved and the armed militants who took its place shuttered well-known drug-selling locations and dealt ruthlessly with users and dealers as part of a system of summary justice for wrongdoers that reportedly included military tribunals and executions.

Their actions won the approval of many locals. Tatiana Boyko, an engineer and mother from Horlivka whom I met in a camp for people displaced by the war, told me the best thing the DNR did last summer was to close pharmacies selling prescription medications used to manufacture krokodil, the street drug that destroyed Ruslan’s jaw. “In two days, they closed everything down, and [krokodil] disappeared,” she said. “And they closed all the bars where our Horlivka men got drunk. DNR guys dragged them off by the scruff of the neck. Next day everyone was sober.”

“I think that’s a good thing,” she said.

But it wasn’t only illegal drug users, dealers, and alcoholics who were targeted. Ruslan was not using street drugs at the time he was picked up — only medically controlled and prescribed methadone. Dima, a social worker from the same Horlivka harm-reduction program, was detained for several days because he had syringes in his car; militants accused him of being a drug dealer and when he was eventually released, told him he was lucky to get out alive.

Dima said he recognized several clients of his program among the militants who locked him for three days in the basement of a Horlivka municipal building. Many medics and social workers providing ST and harm-reduction services — who do not want to give their surnames for fear of retribution — tell a similar story. “The war on drugs was all just for show,” Irina, a social worker from Luhansk, told me. “The militants still come to us for services. Just not in their uniforms.”

And, both social workers and their ST clients say, illegal drugs have returned to the region — just managed by different bosses, sold for higher prices, and, they suggest, likely to be from a new source: Russia. In Luhansk, the old synthetic drugs like krokodil have been replaced by heroin, widespread in neighboring Russia but previously almost unknown in Ukraine.

“Suddenly these new dealers appeared whom no one touches,” said Kolya, an ST patient who in better days worked as a builder to support his young son. “There are never less than 10 people in line for doses all nicely wrapped up in little white packages.”

Kolya knew this from experience: He went back to street drugs when his ST program was interrupted late last year. Sites still providing substitution therapy have not been closed down by the militants, although Nikitin of the LNR was unwilling to confirm whether his regime would allow ST to continue. Methadone is banned in Russia, which backs the breakaway region, and in Crimea, 800 patients lost access to ST overnight when Russia annexed the peninsula last March.

But Kolya, one of 600 ST patients in rebel-controlled Donbass, lost access to the therapy because the war with Ukraine has cut supply lines of medical drugs, including those used for ST.

National delivery companies refused to deliver methadone via militant-held checkpoints (because it is a narcotic, Ukrainian law requires an armed escort for its delivery). The International HIV/AIDS Alliance in Ukraine, which coordinates ST throughout the country, tried to solve the problem by transporting methadone — supplied by international donors — by plane. The day after the first and only air delivery in May, Donetsk airport was bombed. Other solutions, such as recruiting military forces to guard deliveries, also failed; the last delivery to the rebel republics was in July. Then, on Dec. 1, 2014, Ukraine officially halted all funding and supplies to areas not under its control — including medical supplies like methadone and anti-retrovirals for HIV.

By late February, only four of 13 ST sites in separatist-controlled Donbass had any methadone left.

“We’re at a dead end,” said Anya Nikolaevna, a doctor from the Luhansk drug treatment clinic in December. Outside her office, ST patients from another site, where the very last methadone doses had been given out two days earlier, were waiting — but there was nothing to wait for.

Since April 2014, the International HIV/AIDS Alliance in Ukraine has helped over 200 ST patients from Crimea and Donbass find temporary places on ST sites elsewhere in Ukraine. But funding and places are limited, and for many ST is a lifelong therapy. As doctors in Donbass reduce methadone doses to stretch remaining supplies, many patients have turned back to street drugs to lessen the pain of withdrawal.

“Lots have started to get high again,” said Andrey, 42, a former patient from the Donetsk ST program, and a supporter of the DNR before he, too, was picked up by militants, held for several days, and threatened with being forced to dig trenches. “If the methadone dose is reduced, you have to add something. And under shelling all the time, you have to find some way to cope.”

The militants’ harsh penalties, coupled with unfamiliar drugs on the streets and dwindling access to harm-reduction programs, may set up east Ukraine for a devastating return to the 1990s, when high-risk drug use and HIV and other infections claimed many lives.

“Either overdose, imprisonment, or death,” said Kolya from Luhansk. “There’s no other possibility.”

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