Drug Services in the USSR
New age philosophy or free market capitalism? Russian drug treatment services are changing. Philip Fleming, Mike Poling and Annie Feltham report
We have recently been involved in an exchange with Russian specialists in substance misuse.
This developed from the interest of one of the authors, a Soviet specialist, in the problems of drug abuse in the Soviet Union, who on a visit to St.Petersburg in 1988, met a psychologist, Dr Meiroyan who had set up clinics for drug addicts, alcoholics and smokers under the general auspices of the St Peters-burg State Institute for Post Graduate Medical Studies. On a visit to the UK the following year, Dr Meiroryan saw a number of drug and alcohol services, including some in the Wessex region. This led to a further exchange; two of the authors visited drug services in St Petersburg and Moscow in the Autumn of 1990, followed by the visit some weeks later by Soviet colleagues to see services in the Wessex Region. These exchanges were supported by the British Council, as one of their UK/USSR collaborative projects, aimed at promoting scientific and technical cooperation between the two countries.
The treatment of substance misuse is based upon the state system of narcological clinics which have been set up over the past ten years as narcology has developed as a separate discipline. Narcology embraces all forms of substance abuse. Treatment is aimed mainly at alcoholism, with smoking and drug addiction taking second place. A substance is deemed to be a narcotic if it is on the list of officially proscribed drugs (i.e. cannabis and heroin). The Soviets subscribe to the disease model of addiction. There are some 500 narcological clinics and over 10,000 specialist narcologists; most of these are doctors though some are psychologists. The training of these specialists has been limited, consisting of short courses from one to three months in length. It is acknowledged that narcological clinics are failing to offer adequate services for those with drug problems2. There are a number of reasons for this. Addicts are officially registered, and their names passed to the police. If they are picked up on a minor charge, they are required to submit to treatment; the alternative is a custodial sentence. Addicts in custody also have to undergo a form of compulsory treatment, labour therapy, in a correctional institution. Of those receiving drug treatment, 80% are there because they have no choice. The Soviet authorities have become concerned about these deterrents and have recently introduced anonymous treatment on a trial basis.
The conventional treatment system is hospital based and medically oriented. Only a small proportion of beds are allocated for drug misusers, most being allocated to alcoholics. People are admitted principally for detoxification. There is relatively limitid psychological support, the main rehabilitation being in the form of work therapy. This usually involves working in the unit’s own shops, or a local factory, while still living in the hospital. The hospitals we visited were very reminiscent of psychiatric hospitals in the UK twenty years ago. Staff were principally medical, with the doctors wearing white coats and uniformed nurses clearly occupying a subordinate role-, Detoxification mainly employed tranquillizers and vitamins; clonidine was used in some places, although this was not always easy to obtain.
We were interested to see the use of some alternative therapies such as herbal remedies and acupuncture for detoxification. Acupuncture has a respected place in Soviet medicine which is less hidebound by orthodoxy than our own system, and we met one doctor who specialized in treating substance abuse problems with acupuncture. The medical orientation of Soviet narcology was underlined for us but the impressive range of scientific research that we saw taking place. Most of this was in the alcohol field and was aimed at discovering a physical basis for alcoholism.
Psychological methods of treating substance abuse were limited until very recently to the use of hypnotherapy, and something termed ‘rational’ psychotherapy, a distinction informed by the Marxist Leninist rejection of Freudian psychoanalysis. In this form of treatment, ‘the physician, without regard to his or her age, has to assume the position of an older friend or counsellor’4. This rather paternalistic approach fits the hitherto exclusively medical model of treatment. However, this is beginning to change as adoption of the twelve step model used by Alcoholics Anonymous indicates. Contact with AA groups from the USA has begun to revolutionize the thinking of a number of senior narcologists that we met in the Soviet Union. There are several AA groups in both Moscow and St Petersburg, and two years ago a Narcotics Anonymous Group was set up in St Petersburg by Meiroyan and an ex-user. Such groups aim to pro mote self-determination, the encouragement of people to make change in their lives and mutual support but their major advantage is that they take place without the members worrying that the authorities might discover their identity. These are all new perspectives for the Soviet narcologists.
On visiting the UK, our Russian colleagues were particularly interested in the treatment philosophies of the residential units that they visited. These included Clouds House, whose programme is based upon the Minnesota model, Alpha House, the first UK concept house, and the more recently opened Wessex Regional detoxification unit in Portsmouth. Clouds House works to a clearly defined philosophy, but the case of the other two units, we were hard put to define their approach easily, as they had drawn eclectically on a number of different approaches. We realized that in trying to define how these units worked we had to articulate a number of basic assumptions about clients’ individual rights and responsibilities, concepts that were new to the Soviets, but which we took for granted. In talking to the clients at these establishments the point that came across most strongly was that the effectiveness of such programmes was related to the extent to which clients felt in control of their lives, and were able to accept responsibility for themselves. It was apparent that it would not be easy to transplant such a programme into the Soviet Union without some changes in the attitudes of the Soviet people. The attraction of the Minnesota model to the Russians lies in its acceptance of the disease model of addiction.
Also of interest to the Russians were the community-based services for drug misusers. There is little in the way of community services in the Soviet Union; indeed, it was pointed out to us that in the drugs field historically the police force has carried out this function. The role of the police is extremely complex and somewhat contradictory; on the one hand it is the agency which implements the punitive approach to drug users (through the application of the penal law), on the other hand it has a more humane response to drug use than is sometimes found in the medical profession itself. Social Services Departments as we know them do not exist, as training for social workers is still in its infancy. The concept of an informal client centred service based on principles of accept ability and accessibility is foreign to the Soviet tradition of law governed, hospital-based state narcology services. One of the advantages of our system is that we can make contact with drug misusers then they want help, while the Soviet system actively discourages contact with services until the user has no choice in the matter. The Russians were interested in the small part that doctors played in the overall care of drug misusers in the UK, as in their country doctors are the dominant professional group, although their training in narcology is often poor. The multidisciplinarv team with which overlapping responsibilities, equal status of team members and democratic decision making is a new concept.
A change in Soviet law in 19-87 has allowed for the setting up of cooperatives - the rough equivalent of a small business. Essentially this has been the start of officially sanctioned private enterprise and groups of doctors and health workers have set up their own cooperatives. Dr Artak Meiroyan has founded ‘Narcolog’, a cooperative aimed at dealing with alcohol and tobacco dependence in St Petersburg. Their scope is limited as the law prohibits the private treatment of drug addiction. However, such cooperatives are popular with clients, due to their ability to offer more flexible treatment regimes, and take greater account of clients views and consequently, are increasingly attracting senior narcologists into the private sector. If the cooperatives are allowed to treat drug misusers it is likely that this will stimulate improvements in treatment. However positive this sounds, it has to be set against a situation where the state still governs health service provision as it has done almost every other side of life, and this has made innovation very difficult. At the time of writing, the cooperatives, representing the emerging private sector, were still very controversial, but the Soviet government appears to be moving away from the whole-sale freeing up of economic activity, and it remains to be seen how effective a force for change the health cooperatives will prove to be in the long term.
The subject of HIV/AIDS and drug misuse does not yet have the same priority as in the West, though it is being pushed up the agenda. When we explained our concern about the spread of HIV among drug injectors, we were generally met with blank expressions. There is an absence of research about the incidence of HIV and a lack of information among medical staff. There are 3000 addicts officially known in St Petersburg, and we were told that none were HIV positive; HIV testing is obligatory for those whom the state considers ‘at risk’. Of 100 acknowledged people with AIDS in the Soviet Union in 1989, only four were reported to be drug misusers, but official statistics are generally accepted as underestimating the true picture. The risk of the spread of HIV infection among drug users is not seen as a problem. The prevailing treatment model is that of abstinence, and the provision of substitute drugs such as methadone is considered unacceptable.5 Soviets found the concept of harm minimization, the current philosophy of care in the UK, difficult to understand. We did meet one narcologist who thought syringe exchange schemes should be considered, but in due to a major shortage of disposable medical equipment, such schemes would be unattainable at present.
What were the benefits of this exchange? The very different cultures, attitudes to drug misuse and traditions of care and treatment between the Soviet Union and the UK made us realize that we did not necessarily share the same assumptions. The process of explaining and justifying our different approaches was a valuable exercise in itself. The Russians are interested in our community services and we are looking at ways of providing more training and experience for their specialists. We are planning two projects. The first, due to run from the summer of 1991, is a small scale clinical trial to test the efficacy of acupuncture in treating the symptoms of withdrawal. We are inviting a Soviet acupuncturist to Portsmouth for three months in order to provide the treatment. The second venture is a much more ambitious project, and aims to introduce the multidisciplinary model of drugs work to the Soviet system of treating drug and alcohol problems.
1 Feltham, A. 1989, Drug and alcohol abuse Leningrad. New opportunities for social research. Sov. Educ. Study Group Bull., Vol. 7, No. 1, pp.1-9
2 Meiroyan, A.A. 1990, Changing Perspectives of Nar-cological Services in USSR. Abstracts: International Conference on Healthy Lifestyles, S.M. Kirov Post | graduate Medical Institute, St. Petersburg.
3 Kramer, J.M. 1988, Drug Abuse in the Soviet Union. Problems of Communism, 37, pp. 28-40
4 Altman, R. 1984, Substance Abuse in the Soviet Union. Journal of Substance Abuse Treatment, Vol. 1,pp.219,221
5 Babayan, E.A. 1990, Medico-legal aspects of treatment and prophylactic care of narcotic drug addicts . Drug and Alcohol Dependence, 25, pp. 209 212