The New York Times - July 22, 2008
Michael Schwirtz

The focus of their outrage was methadone, a drug prescribed by doctors around the world to wean addicts from heroin. A synthetic form of opium, methadone is central to a therapy endorsed by the United Nations and 55 countries, including the United States.

But not Russia. Though heroin abuse is widely linked to the country's H.I.V. epidemic and the spread of criminality, the issue of methadone treatment is all but taboo here.

Methadone, typically taken by mouth in liquid form, blocks addicts' cravings for heroin by binding to the brain's opioid receptors. Methadone has critics in many countries, who argue that it replaces one form of opiate addiction with another; in Russia even talking about it can provoke legal sanction.

"There is no possibility to have a normal discussion about this issue," said Dr. Vladimir D. Mendelevich, director of the Institute for Research Into Psychological Health, in Kazan, 500 miles east of Moscow.

After the conference in February, which Dr. Mendelevich helped organize, Moscow's legislature began an inquiry into whether he had engaged in "drug propaganda," and it called on prosecutors to open a case against him, he said.

Several years ago, prosecutors filed administrative charges against him after he posted reports on methadone treatment to his Web site. The charges were eventually dropped, but he was forced to take down the site. "If I revive it," he said, "another case of narco-propaganda will be opened, and there would likely be some kind of verdict."

While Dr. Mendelevich struggles with his opponents, Russia continues to suffer a steady increase in intravenous drug use. Drug addiction was nearly unheard of until the Soviet Union fell. But as borders opened and the economy collapsed, illicit narcotics gushed in.

Estimates on the number of drug addicts in Russia range from three million to six million. Most use intravenous drugs like heroin and other opium-based narcotics that largely originate in Afghanistan and easily flow across the country's porous southern borders.

The epidemic has put added strain on Russia's struggling health care system and has posed a serious challenge to law enforcement.

Intravenous drug use is also the leading cause of H.I.V. and AIDS in Russia. It accounted for about 66 percent of new cases in 2006, and the epidemic continues to grow, though not as quickly as in the past, according to the United Nations' AIDS agency. The Russian government estimated that as of 2007 more than 400,000 people were living with H.I.V., out of a population of about 142 million. (The United Nations' estimate from 2005 was 940,000; by comparison, 1.2 million Americans, out of a total of 300 million, were living with H.I.V.)

Many international experts say methadone treatment is critical to controlling the epidemic. Coupled with needle exchange (already in use in some Russian cities), the therapy could "largely stop the spread of H.I.V. among injecting drug users," Peter Piot, the executive director of Unaids, the United Nations agency, said in May.

Without methadone, he said, the epidemic is not likely to be stopped. "I may be wrong, but I don't see it happening."

Russia's health establishment is not impressed.

At the same AIDS conference, Dr. Gennady G. Onishchenko, the country's chief sanitary doctor, the equivalent of surgeon general, said health officials "are not convinced that this is effective," and added, "There is little optimism for legalizing methadone therapy in the near future."

Dr. Onishchenko declined to be interviewed on this issue, as did Dr. Nikolai N. Ivanets, Russia's top narcotics specialist.

Dr. Ivanets, an aggressive opponent of methadone, who gave opening remarks at Dr. Mendelevich's conference, attacked the professional credentials of the conference participants and singled out Dr. Mendelevich for special scorn.

"Everyone has become so annoyed with methadone, with the exception of a few groups of people who call themselves specialists," Dr. Ivanets said at the conference. "This is a group of dissenters."

Methadone opponents in Russia say the therapy entraps patients in lifelong addiction; others accuse Western countries of pushing the treatment on Russia for commercial gain. There are also fears that methadone could seep into the black market, given the high level of corruption at many Russian clinics.

Russia's own treatment methods, though not perfect, they argue, sufficiently address the needs of addicts.

Then there are the pro-Kremlin youths from groups like Young Guard - the youth wing of the dominant United Russia party - whom the government routinely mobilizes to harass high-profile dissenters. At their demonstration outside the methadone conference, protesters held placards and waved flags, calling methadone "a dead end."

But some Russian specialists, along with current and former addicts, have begun to challenge the official line.

"Scientific arguments, evidence-based data, are not convincing them," said Evgeny M. Krupitsky, the head of a laboratory that conducts research on drug addiction at St. Petersburg State Pavlov Medical University. Russian methodology regarding opiate addiction "is not evidence-based," but relies on "subjective opinions of major leaders in this field."

Though not every addict would benefit from methadone substitution therapy, more than 60 percent of Russian users would, Dr. Krupitsky said.

Many researchers on both sides of the methadone debate agree that only a small fraction of the heroin users in Russia seek treatment at detoxification centers and that most who do - some say more than 90 percent - relapse into drug use shortly after leaving.

At such clinics, doctors encourage immediate abstinence from drug use, rather than the gradual process that methadone substitution therapy entails. Patients are often given sedatives and painkillers to cope with withdrawal symptoms. Many are then released after a month or two with the expectation that they will remain clean. They rarely do.

"You only have a chance to stay sober for one month," said Masha A. Ovchinnikova, a former heroin addict from St. Petersburg, who said she quit largely with willpower (and anti-withdrawal drugs provided by "contacts"), while friends remained mired in addiction or died.

"If you go on detox once and then twice and then three times, you realize that it doesn't work for you," Ms. Ovchinnikova said. "You don't want to ask for help from the medical system; you don't believe in it."

Supporters of methadone treatment or other opiate substitution therapies argue that if properly administered by medical professionals, the treatment method breaks addicts' dependence on illegal narcotics, acting as a surrogate to ease withdrawal symptoms, while decreasing the risk of overdose, criminality and H.I.V. transmission.

"I am for any scientific, medical approach to treatment," said Albert Y. Zaripov, a former heroin addict who counsels users in Kazan.

He began shooting heroin more than a decade ago with a group of 10 friends. Four are in jail, another four remain chained to their addictions, and two died. He alone quit, but after he had contracted H.I.V.

"If there is another treatment besides substitution therapy, there's no problem," he said. "But I haven't heard of anything else that has helped or that is more effective."

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