Russian Federation

"Recently, this opposition to science and human rights reached a new frontier. In 2010, Russia’s Chief Narcologist announced his endeavor to create a four-level system of “social pressure” in order to respond to the country’s “drug problem” [26]. The first level of this system involves “early detection” of drug use by way of school and workplace testing; the second level is voluntary drug treatment; the third level is compulsory treatment by referral from the criminal justice system; and the fourth level is compulsory treatment within the criminal justice system. By 2013, this system was fully implemented as state policy. Despite the fact that compulsory drug treatment was proclaimed unconstitutional in Russia in 1989, the punitive principles underlying Russia’s current drug policy allowed for widespread ignorance of this fact—not an unusual practice in Russia [27]. Correspondingly, in 2013–2014, several federal laws and regulations were amended to establish compulsory drug treatment [28–30], purportedly to motivate DDP and people who use illegal drugs to undergo medical treatment and rehabilitation [31]. For example, these amendments empower law enforcement agencies to coerce PWUD to undergo drug treatment and rehabilitation, empower courts to issue drug treatment orders to people who commit drug-related administrative offenses (such as non-medical use of narcotic drugs or possession of insignificant amounts of narcotic drugs) or to DDP who commit minor crimes (such as theft or the possession of significant amounts of drugs for personal use), introduce administrative punishment of up to 30 days of imprisonment for evasion of court-imposed drug treatment or rehabilitation, and require drug treatment and rehabilitation organizations to report to police those patients who do not fulfill court-imposed treatment or rehabilitation orders."

"People who use drugs (PWUD) are one of the most stigmatized and marginalized populations in Russia [1, 2]. People who inject drugs (PWID) are particularly vulnerable to HIV infection, HCV infection and fatal overdoses (OD) [3–7]. Unfortunately, harm reduction programs that have been proven to be effective for combatting HIV, HCV, and OD among PWID [8, 9] are not officially endorsed by the Russian government, their number is limited and access to them is low [10]. Moreover, the number of needle and syringe exchange programs (NSPs) in Russia has been decreasing since 2010 [11], while opioid agonist therapy (OAT) remains illegal [10]. In addition, harm reduction services were reported to be unattractive to young PWID in Russia [12].

"Thus, there is an urgent need for alternative ways of providing harm reduction services to improve their accessibility among a wider population of PWUD in Russia. This is especially true for harder-to-reach populations, such as young PWUD. One such way to increase accessibility is by integrating harm reduction services into online platforms."

"Based on the discourse analytical perspective (see Van Dijk, 1995, 2006, 2010) two main ideologies could be identified that constitute the basis of the Russian parliamentary discourse on illegal drugs. Firstly, an external threat ideology was identified, in which the drug problem is primarily regarded as an external problem, coming into Russia from other countries. In the Russian Duma, illegal drugs are seen as posing a threat to Russian society, mainly as a result of Afghan opium production. It is here possible to draw some parallels with the early US war on drugs rhetoric. One similarity with the early US war on drugs rhetoric is the strong focus on heroin as one of the main problems. For example, when President Nixon declared a “war on drugs” in 1969, the focus was on the growing heroin problem (Boyum & Reuter, 2005). Another similarity with the early US war on drugs rhetoric is the focus on supply reduction. In the US, for example, several American presidents have devoted resources to supply control efforts, e.g. Nixon, Ford, Carter, Reagan, Bush (Mathea, 1996). As in the US, this study of the Russian parliamentary discourse indicates a focus on supply rather than demand when debating the drug problem. For example, the politicians place a major emphasis on controlling the drugs entering Russia from foreign countries (especially Afghanistan), but focus less attention on rehabilitation and prevention. Secondly, a prohibitionist ideology was identified in the Russian parliamentary discourse. For example, there was a general consensus among politicians that Russian drug policy and legislation was too weak and that a more repressive policy was needed. However, this idea of drug prohibitionism is not unique to the Russian context but is similar to drug prohibition ideologies in other countries. For example, during the war on drugs in the US, prohibitionists defended strict legal sanctions against all illicit drugs (MacCoun & Reuter, 2001).

"When analyzing political discourse it is often easier to identify what is said explicitly.

"However, it is also important to identify ideas and ideologies that are not put into words. Based on the extensive research on injecting drug use and its impact on the spread of HIV in Russia, it is surprising that the Russian politicians examined in this study devoted so little attention to this topic. Further, the topic of substance treatment and injecting drugs was not discussed in the debate. It is therefore possible to argue that the results of this study indicate an absence of a harm reduction ideology in the Russian political debate."

"Analysis of court statistics demonstrates that the 2013–2014 amendments have not led to the expected outcome of “motivating” PWUD to undergo drug treatment or rehabilitation. Only about 2% of people convicted for drug administrative offenses chose to undergo treatment rather than punishment (about 1500 out of more than 70,000) [32] and only about 1% of 48,557 people who were involuntarily ordered to undergo drug dependence treatment remained drug-free within a year or more after treatment. Publically available judgments indicate that people have either simply not shown up for their appointments with narcologists or failed to visit narcologists after diagnostics (after which narcologists report truant patients to the police) [33]. Despite this obvious ineffectiveness, narcologists continue to express strong support for this system of “social pressure.” In June 2017, the Ministry of Health of the Russian Federation sponsored a large conference of narcologists. The conference’s final resolution included recommendations to health institutions in Russia to form a system of social pressure for people who use psychoactive substances, including a mechanism of legal “motivation” for treatment and rehabilitation as an alternative to administrative and criminal liability for people committing drug crimes. The same conference endorsed a bill to be introduced to the Federal Parliament in order to expand the coercive treatment measures of 2013–2014 to “problem alcohol users” [34]."

"One of the most common solutions to the drug problem in the Duma debate was that there was a need for more severe legislation. Politicians argued that Russian drug policy was too weak and that a more repressive policy was needed – for example that more legal substances should be classified as illegal, that the drug consumption legislation should be more severe or that the death penalty should be introduced for drug traffickers. Interestingly, only a few politicians discussed prevention and/or treatment as solutions to the problem. When prevention was discussed, many different forms were mentioned, such as school prevention, media campaigns and/or other forms of information campaigns directed at the public. Another form of prevention that the politicians talked about was protecting young people from information about drugs by educating and informing children about traditional Russian values. In line with this idea, some politicians were also overly positive about the use of different forms of legislation to control information about drugs, for example, by means of a propaganda law. The idea of criminalizing drug propaganda is also in line with the rhetoric used by President Putin. In October 2019, Putin called on lawmakers to toughen the anti-narcotics legislation and to impose jail sentences on those found guilty of online “drugs propaganda” (Carroll, 2019). However, the propaganda law has been heavily criticized by NGOs in Russia, and there are media reports about NGOs being sentenced to fines on the basis of this law because they are accused of having published propaganda on drugs (Carroll, 2019). The drug propaganda law has also impacted the situation for anti-drug NGOs in Russia. For example, the Andrey Rylkov Foundation decided in April 2020 to limit access to its website containing materials on Russian and international drug policy, health and human rights resources for people who use drugs (International Drug Policy Consortium, 2020)."

"According to multiple sources, drug users in Russia have numbered between 7.3 to 8.5 million for the past several years. At an October 2017 Saint Petersburg conference, experts reported that in 2016, there were 637,482 people incarcerated in Russia, for which 63 percent were for drug offenses, and 10 percent of whom are HIV positive. In addition, 54.5 percent of Russian narcologists list religion as 'the most suitable therapy' for drug addiction, and as a result, drug addiction in Russia is typically treated with antipsychotic drugs suited to treat schizophrenia, instead of agonist and antagonist agents. Analysts have also ascribed spotty progress and metrics to poor interagency and inter-sectoral cooperation, and to the lack of a cohesive national rehabilitation program."

"Harm reduction, while not always in these exact words, is mentioned in national government policies in 25 of the 29 countries in the region. Needle and syringe programmes (NSPs) are available in 27 out of 29 countries (excluding Turkmenistan and Bulgaria), and opioid agonist therapy (OAT) in 26 countries (except Russia, Uzbekistan and Turkmenistan). However, the coverage of services in most of the countries doesn’t reach the minimum 20% recommended by the World Health Organization (WHO)[4] and the quality of services remains low and not client-oriented. Consequently, nearly half of new HIV infections in 2019 in the post-Soviet part of the region were attributed to injecting drug use.[63]

"Twenty-one countries provide OAT in prisons, and only five have needle and syringe programmes (NSPs).

"Naloxone and overdose prevention education is explicitly stated as part of the harm reduction programme for people who use drugs in Georgia, Kyrgyzstan, Moldova, Tajiskistan and Uzbekistan.[9] Take-home naloxone is available at harm reduction sites in Estonia, Kazakhstan, Kyrgyzstan, Moldova and several cities in Russia, with support from international donors."

"As noted above, human rights organizations and UN bodies have documented human rights violations against PWUD [People Who Use Drugs] in Russia, including the absence of drug dependence treatment for people living with HIV and tuberculosis [56], the use of unscientific methods and the drug user registry in drug dependence treatment [57], and the prohibition on OST [57, 58]. Moreover, the UN Committee on Economic, Social and Cultural Rights (CESCR) has urged Russia to apply a human rights-based approach to PWUD so that they do not forfeit their right to health [59, 60], while the UN Human Rights Committee has recommended that Russia provide effective drug dependence treatment to people in police custody [61] and the UN Committee on the Elimination of Discrimination against Women has recommended that Russia provide drug-dependent women access to OST [62]. As of September 2017, there were also at least five applications pending before the European Court of Human Rights concerning the human rights of PWUD.³

"However, human rights violations arising from punitive drug policy are not limited to PWUD. Arguably, narcologists’ human rights are also infringed when Russian drug laws criminally prohibit evidence-based drug dependence treatment such as OST, thus subjecting narcologists who are willing to provide OST to their patients to life imprisonment for drug trafficking. Narcologists are also prohibited from openly supporting harm reduction activities, such as needle and syringe programs, because such support can lead to administrative or criminal sanctions for violations of drug propaganda laws [63, 64]. According to a former Chief Narcologist, Nikolay Ivanets, Russian narcologists would never speak in favor of OST because of the risks of prosecution [65]. Russian narcologists are pulled in two directions, representing polarized sets of obligations. On the one hand, they have responsibilities as doctors, acting in the best interest of their patients, which ostensibly includes employing the most effective, evidence-based treatment methods. On the other hand, narcologists are prohibited from providing or promoting such methods of treatment and care, such as OST and harm reduction programs, under the threat of criminal and administrative sanctions."

"Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Romania, Russia, Tajikistan, Turkmenistan, Ukraine and Uzbekistan). Together, these 18 countries accounted for over 87% of TB mortality in the WHO Europe region with the highest in Turkmenistan (10.4 deaths per 100,000), followed by Azerbaijan (10.1) and Ukraine (8.4). In addition, an estimated 20% to 25% of TB cases in Eurasia go undetected.[19]

"The largest proportion of new and relapse cases (78,258, or 34.4%) come from Russia. The countries with the absolute highest number of TB cases over 10,000 are Russia (78,258), Ukraine (36,000), Uzbekistan (23,000), Romania (13,000) and Kazakhstan (12,000). There were an estimated 30,000 HIV-positive TB cases, with Russia (53%) and Ukraine (27%) contributing to the highest burden of coinfection. The TB notification rate exceeds 1,000 cases per 100,000 prison detainees in Azerbaijan, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine. The highest TB-related risks in prison are calculated to be in Slovakia (40.7), followed by Czechia (24.9), Ukraine (23.8), Russia (23.5) and Azerbaijan (22.1). Russia accounted for almost half of the deaths in the WHO EU Region in absolute numbers. Although few countries report TB in people who inject drugs, higher rates of notification (new cases) among this group supports evidence that people who use drugs are at higher risk of TB.[20]

"OAT and drug treatment, even if available in the country, are largely unavailable in TB treatment facilities (for example Kazakhstan, Russia, Ukraine) and facilities are often restricted from prescribing controlled substances.[21] Consequently, people who use drugs often come into contact with the health system at late stages of the disease and are forced to interrupt treatment which, in turn, leads to high prevalence of multidrug-resistant TB.[1]"

"Now, when the regressive revision of criminal drug policy has been completed and when, based on the new rules, new amounts have been approved for defining large and exceptionally large amounts, two conclusions can be drawn on the basis of the figures:

"1) Since February 11, 2006 there are additional grounds for the criminal prosecution of people who use narcotics.

"2) Despite the most recent changes, compared with the situation existing until May 12, 2004, today's position does not seem to be as universally repressive as it was during the period when Academician Babayan's Summary Table was in use.

"This can be confirmed by a comparative analysis of the threshold of criminal liability with respect to the most important substances on the list (table ​(table11).

"If we consider the whole list, containing 232 items, we find that a decrease in amounts defined as large occurred in only 49 cases, while there were increases in 140. These amounts were increased in the majority of listed substances.

"However, almost all of the 140 substances for which the amount deemed large was increased are substances only rarely involved in illegal trafficking, while decreases in threshold occurred for the majority of popular narcotics.

"The bar for the amount criminally punishable decreased with respect to that established on May 12, 2004: by a factor of two for heroin (from 1 to 0.5), by a factor of five for opium (from 5 to 1 grams), for marijuana from 20 to 6 grams, for hashish from 5 to 2 grams, for ketamine by a factor of 5 (from 1 to 0.2 grams), for cocaine by a factor of three (from 1.5 to 0.5 grams), for LSD by a factor of 30 (from 0.003 to 0.0001 gram), for pervitine from 0.5 to 0.3 grams, for amphetamine by a factor of 5 (from 1 to 0.2 grams), and for ephedrine from 0.5 to 0.2 grams."

"The latest information, obtained directly by us from the Ministry, covers the year ending 2017, and reports the number of newly registered PLHIV [People Living with HIV] has increased by 105,844. Clearly, this is not an exact measure of incidence, but it gives an indication that numbers continue to rise unabated. Reasons for the absence of progress in Russia are numerous and include insufficient access to sterile injecting equipment, unavailability of opioid substitution therapy, and a shortage of treatment in populations where it is most needed, namely people who inject drugs and their partners, sex workers, and men who have sex with men."

"Corruption, misappropriation and embezzlement of public funds, tax evasion, fraud, and drug trafficking generate significant proceeds. There is a large shadow economy approaching 13 percent of the Russian GDP [Gross Domestic Product], according to the latest estimates by the Federal Statistics Service. Although cash in circulation as a percentage of total money supply has declined from a historical peak of 43 percent on November 1, 1998, to 21.6 percent on September 1, 2020, there was a 23.7 percent surge in the value of cash in circulation in January-September, largely related to COVID-19 restrictions. Financial flows from illicit activity linked to Russia have threatened weak financial institutions in neighboring countries; however, they also make their way to global financial centers, often through opaque shell companies.

"The total amount of funds moved offshore through Russian commercial banks via suspicious transactions declined 72.2 percent year-on-year in the first half of the year to approximately $259.5 million, down from approximately $474.4 million in the same period in 2019, according to the Central Bank of Russia (CBR). Although Russia has made some progress on AML [Anti-Money Laundering], various investigations have alleged the existence of schemes designed to launder billions of dollars out of Russia."

"Official corruption at all levels of government constitutes one of the largest sources of laundered funds. Russia is also a transit and destination country for international narcotics traffickers, particularly from Afghanistan. Cybercrime remains a significant problem, and Russian hackers and organized crime structures continue to work together. Criminals launder funds through banks, hawala networks, real estate, industrial entities, and luxury goods.

"Although Russia has encouraged domestic development of blockchain-based technologies, the Russian government does not have a consistent position on the regulation of virtual currency.

"There is a large migrant worker population in Russia. Many remittances are sent through an informal value transfer system that may pose vulnerabilities for money laundering. Gaming is only allowed in specified regions. The FIU monitors casinos for AML/CFT compliance, while other agencies supervise other parts of the gaming sector. Online gaming is prohibited."

"Drug addiction in Russia is typically not treated according to evidence-based modern protocols but often with “cold turkey” abstinence-focused programs or antipsychotic drugs suited to treating schizophrenia and other mental illnesses.  Civil society experts have criticized Russian addiction treatment and rehabilitation programs due to poor interagency and inter-sectoral cooperation, as well as for the lack of a cohesive national rehabilitation program."

"Anti-drug legislation. 95% of all drug crimes registered in Russia in 2013–2014 were prosecuted under articles 228 and 228.1 of its Criminal Code. The severity of a penalty under these articles depends on the type of drug offense (drug use or drug sale) and on the weight of the drug seized, which are classified via threshold quantities as “significant”, “large” or “especially large” (Appendix B, Tables B2 and B3). According to the law, the drug quantity seized is determined not by the weight of the pure drug substance but by the weight of the entire mixture. Therefore, if a police officer seizes, for example, one gram of heroin mixed with two grams of sugar, it will be considered to be three grams of heroin.

"The punishment for drug possession of a “significant” quantity, with no intention to sell, is a fine of up to approximately $1,13810, corrective labor, restriction of liberty, or imprisonment for up to three years. For “large” and “especially large” quantities, the punishment is imprisonment for three to ten and ten to fifteen years, respectively. In the case of voluntary surrender of drugs to a police officer and active assistance during the investigation, an offender is exempted from criminal liability. If the quantity of drugs seized is less than significant, only administrative penalties of a fine of up to approximately $14210 or arrest for up to fifteen days can be imposed.

"Drug sale is punishable by imprisonment for four to eight years if the quantity is less than “significant”, eight to fifteen years for a “significant” quantity, and ten to twenty years for a “large” quantity. “Especially large” quantities carry a fifteen to twenty years or life sentence. Thus, the crime is serious if the quantity of drug seized is less than “significant”, and most serious if the quantity is “significant” or higher."

"The prevalence of hepatitis C among people using drugs is very high in Eurasia, varying between 15% and 94%. Hepatitis C prevalence among people who inject drugs is above 50% in 18 countries in Eurasia, up from 16 in 2018 (see regional table, p.82). Russia is one of the four main contributors to the hepatitis C burden among people who use drugs in the world.[27] The main barriers in the region to reaching the goal of eliminating hepatitis C by 2030[28] are poor coverage of harm reduction services, restrictive drug policies, criminalisation of drug use, poor access to cost-efficient harm reduction services, low hepatitis C testing, poor linkage to care and treatment, restrictions for accessing direct-acting antiviral therapy and the lack of national strategies and government investment to support elimination goals.[27, 29]"

"Darknet-based drug marketplaces are frequently used by PWUD. 'Empire Market' [13], 'Hydra' (in Russia) [14] and other darknet markets operate similarly to regular online marketplaces: they give vendors and buyers a platform to conduct their online transactions on. However, darknet-based drug marketplaces are more difficult to access as they require special software which encrypts computer IP addresses (e.g., Tor Browser). Transactions are anonymized and performed with cryptocurrencies (e.g., Bitcoin); hence, darknet markets are also called ‘cryptomarkets’. In addition to making purchases on the cryptomarkets, users can also exchange information on the availability of particular drugs, experiences from using them, their effects and potential harms via integrated online forums [15–17].

"The use of drug marketplaces and drug-related online forums to facilitate harm reduction has started to gain the attention of researchers. A number of studies have shown that such online platforms could bring new opportunities to provision of harm reduction services [18–20]. Social media platforms have also shown potential to bring greater access to harm reduction services among PWUD [People Who Use Drugs] [21]. Harm reduction interventions via online platforms are often referred to as ‘web outreach’, ‘online outreach’ or ‘netreach’ work [22, 23].

"Web outreach work implies that harm reduction workers contact PWUD through online platforms and provide them with harm reduction information and counseling upon individual requests of users or distribute harm reduction information publicly via online forums. Such work helps to encourage risk reduction behaviors among hard-to-reach populations of PWUD, who do not attend brick-and-mortar harm reduction facilities [22, 23]. Moreover, the COVID-19 pandemic has introduced social distancing measures and shortages of medicines and harm reduction supplies, which makes it more difficult to provide in-person harm reduction services [24, 25]. Web outreach helps organizations continue to provide harm reduction services during the pandemic."

"Russia has a high prevalence of drug use and has already for some years suffered from a widespread injection drug use epidemic with an estimated over 2% of the population being people who inject drugs (PWID). In 2020, a total of 18,013 people overdosed on illicit drugs and 7,366 died as a consequence, which is a 16% increase compared to 2019 (Sárosi, 25 February, 2022).

"Despite the problems escalation – such as PWID functioning as a major driver of Russia's HIV epidemic (Meylakhs et al., 2019) – the official strategy by authorities has mainly focused on drug traffickers and drug-related crime. During the past 30 years, the Russian Federation has introduced tough measures to combat the spread and use of illicit drugs. Over one fourth of the imprisoned population are estimated to have been punished for drug-related crimes.

"The country is on a path of “treating users like criminals instead of people in need of treatment” (Kauschanski, 2019). A priority by authorities to set up “draconian laws” has been portrayed from the drug users’ perspective, for example in a 2019 story in Deutsche Welle. Examples include getting four years in prison for being caught with just a small amount of drugs (Kauschanski, 2019). The Eurasian Harm Reduction Association (EHRA) describes a misuse of power in a highly punitive and stigmatising environment: “law enforcement agencies have a virtual carte blanche to discriminate against people who use drugs” (EHRA, 2020).

"A study from 2020 that scrutinises extrajudicial and illegal police drug controlling practices found “significant discontinuities in the weight distribution of seized heroin near minimum threshold amounts” (Knorre, 2020, p. 378). Ruling out alternative explanations of the discontinuity, the author Alex Knorre concludes that the most likely source of the revealed discontinuities is police manipulations with seized heroin (Knorre, 2020)."

"The inaccessibility and poor quality of services pertaining to the treatment of drug dependence in Russia have been extensively documented. Treatment methods reported include flogging, beatings, punishment by starvation, long-term handcuffing to bed frames, 'coding' (hypnotherapy aimed at persuading the patient that drug use leads to death), electric shock, burying patients in the ground and xenoimplantation of guinea pig brains⁶². The practice and acceptance of such methods clearly indicate that the government’s approach does not correspond to international drug treatment guidelines.

"Such methods are not only cruel but ineffective. As the Russian Federal Drug Control Service has acknowledged, over 90% of drug treatment patients return to using illegal drugs within one year⁶³. As a result of the ineffective government approach to drug treatment and care, Russia has one of the largest numbers of people who use drugs—government estimate reaches 5 million⁶⁴, while UNODC’s 2009 World Drug Report estimated that 1.6 million people use opiates⁶⁵. Meanwhile, the number of people living with HIV in Russia continues to rise; in 2010 alone, a total of 58,633 new HIV cases were officially registered in the country⁶⁶. Injecting drug use has long been the predominant risk factor, with around 80% of all HIV cases registered in the country from 1987 to 2008 associated with the use of injecting drugs⁶⁷. The government’s refusal to respond adequately to the main transmission risk means that most of the funding goes to the management of the consequences rather than prevention of new infections. It is clear that 3% of the entire budget cannot possibly reach the most vulnerable population in an effective manner, and even the 3% spent on prevention is spent inefficiently."

"Seven years ago, in May 2015, members of the Russian Civil Society Mechanism for Monitoring of Drug Policy Reforms compiled a letter to the UN High Commissioner for Human Rights with the title “Violations of human rights in the name of drug control in Russia” (Russian Civil Society Mechanism for Monitoring of Drug Policy Reforms in Russia, 2015). The situation is aptly summarised by the subheading: “Stigmatizing language, overreliance on punitive restrictions, indifference to human rights, and obliteration of science”. The developments since have accelerated on the same trajectory.

"In 2017, the UN Committee on Economic, Social and Cultural Rights recommended that Russia change its punitive policy approach with an 18-month transformation and to consider decriminalising drugs for personal consumption. But nothing has really changed. In May 2018, the same members of the drug policy reform civil society made an update to the May 2015 report (Russian Civil Society Mechanism for Monitoring of Drug Policy Reforms in Russia, 2018) summarising: “No changes have occurred in Russian drug policy since that time [May 2015]. Russia fails to fulfill its commitment to respect, protect and promote all human rights, fundamental freedoms and the inherent dignity of all individuals and the rule of law in the development and implementation of drug policies” (Russian Civil Society Mechanism for Monitoring of Drug Policy Reforms in Russia, 2018, p. 1)."

"Our research demonstrates that a number of harm reduction-related needs among PWUD [People Who Use Drugs] can be met entirely through web outreach work, while some can only be partially met online. These findings are in line with the existing literature on online platforms bringing new opportunities to harm reduction services provision [18–20]. They also contribute to the growing amount of literature regarding the processes of web outreach work [22, 23] and bring new evidence on how various needs of PWUD are addressed by web outreach services.

"We identified a three-stage process of web outreach work. The process illustrates the benefits that PWUD gain from online harm reduction services provision without face-to-face contact with web outreach workers. An absence of requirement for physical presence of PWUD at a harm reduction organization facilitates greater level of anonymity in comparison with offline harm reduction services provision. In addition, the use of text messages brings greater convenience to PWUD, who do not feel comfortable with discussing drug use-related issues in person. These factors indicate that web outreach work helps to encourage harm reduction behaviors among PWUD who, otherwise, might not seek or have access to brick-and-mortar harm reduction services."

"Revised data for the Russian Federation indicate annual prevalence of the use of opioids to be 2.3 per cent and the annual prevalence of heroin use: 1.4 per cent.⁶¹ Of the 9,263 drug-related deaths reported in 2010, 6,324 were attributed to opioid use."

"Our analysis of the needs of PWUD [People Who Use Drugs] and services provided to them demonstrates two major functions performed by web outreach workers: 1. They can provide certain services completely online, and 2. They navigate clients within the organization in order to match the needs of the PWUD with a person who can address them. Our research on web outreach work indicates an increasing level of efficiency that comes from online provision of harm reduction services. Instead of traveling to a harm reduction facility, PWUD can contact the organization via an online platform. Furthermore, harm reduction services provided entirely online gain particular relevance amidst the COVID-19 pandemic when offline harm reduction organizations experienced new challenges to providing in-person outreach services.

"Our findings suggest that online harm reduction services provision can be improved in terms of accessibility and efficiency. A challenge for web outreach work, as described by informants, was the inability of workers to communicate with PWUD after hours. One possible solution is to automatize some processes with Telegram bots, as it was done with the cases of OD [Overdoses]. Currently, web outreach workers manually send information to PWUD. If automatized, then PWUD themselves could use a bot to get necessary information at any time of the day. However, not all services can be automatized with a bot; therefore, it may be necessary to employ some workers, who could reply to clients’ requests after hours. This is especially important in emergency situations, such as OD. Another way to develop provision of online harm reduction services is to increase their presence on darknet forums. Greater presence could potentially make online services accessible to more groups of PWUD, who request urgent help after hours and/or who do not use Telegram. Another obstacle in increasing accessibility of online harm reduction services was that some clients refused to continue communication with web outreach workers via the phone. More research is needed to explore the needs that PWUD have in such cases, identify the reasons why certain PWUD refuse to communicate via the phone, and explore how web outreach work can be provided in such instances."

"However, one problem markedly reduces naltrexone’s efficacy and has limited its use for treating heroin and other forms of opioid dependence worldwide: patients often do not like it and do not take it on a daily basis. The dropout rate with oral naltrexone has been better in the limited number of patients in whom there is substantial external motivation to remain abstinent, such as physicians who are in monitoring programs and could lose their license if they relapse, those involved in the criminal justice system who could go to prison if they relapse, and those facing loss of employment [1•, 2–4].

"A few US studies have shown positive effects with psychosocial or behavioral therapies. In two, contingency management combined with naltrexone was helpful [5, 6]. In another, naltrexone combined with individual [7] and group [2] psychotherapy yielded positive effects. A third tested a behavioral therapy that used rewards for negative urine tests [8]; however, it had a relatively limited effect and was identified by Nunes et al. [9] as one of several examples indicating that there appears to be a ceiling effect on the degree to which behavioral interventions can be used to improve naltrexone treatment outcomes."

"The science and practice of drug treatment in Russia – narcology – developed out of psychiatry in close collaboration with other state mechanisms of social control, including police agencies (Elovich and Drucker, 2008). Close links between narcology and police agencies remain (Bobrova et al., 2006). Access to drug treatment automatically requires official registration as an addict, which involves the removal of various citizenship rights, such as the rights to employment, as well as exposure to social stigma (Bobrova et al., 2006). The effectiveness of drug treatment approaches (which are modelled on alcohol detoxification methods) remain questionable, are linked to high rates of relapse, and are framed by a policy response at Federal level which prohibits the use of (internationally accepted) methadone and buprenorphine as substitution treatment (Elovich and Drucker, 2008; Mendelevich, 2004; Human Rights Watch, 2007). This policy rests on the rationale that treating addicts as patients would challenge policy discourse that labels drug users first and foremost as 'criminals' (Elovich and Drucker, 2008)."

"The growing number of young people abusing drugs is a serious concern. Worryingly, the overwhelming majority of drug addicts are between 18 – 30 years old. Many of them are unemployed, have a chronic history of offending and commit a large number of crimes to finance their addiction. As is the case in many other countries, the so-called ‘dark figure’ of crime – the mismatch between crime estimates produced by victimization surveys and those recorded by the police - is a well-known concept in Russia and most commentators agree that a relatively small number of opiate addicts are responsible for a staggering amount of acquisitive and violent crime. In this context it is worth noting that the Russian police registered around 12,000 crimes (of which 63 percent were rated as serious or extremely serious) which had been committed by offenders whilst they were suffering drug intoxication.

"The increase in drug abuse amongst otherwise law-abiding people, particularly adolescents, is causing a good deal of concern. Over the last few years, more and more young people have become ensnared in the cycle of drug abuse and crime. In 2006, more than 3,000 adolescents committed drug related crimes. Of these, some 845 cases involved the distribution of drugs. Young people’s increasing willingness to abuse drugs which too often leads to addiction, prostitution and homelessness, poses a real threat to community safety."

"In the three Russian cities participating in this study, we found policing practices targeting injecting drug users (IDUs) to violate health, as well as individual rights. The brutality of police practices violate health directly, but also indirectly through the reproduction of day-to-day social suffering, which in turn can be internalized as self-blame, lack of self-worth, and fatalism regarding risk. These findings illustrate how law enforcement practices, particularly extrajudicial practices, generate an atmosphere of fear and terror, which shapes everyday practices of risk avoidance and survival among IDUs. Policing practices contribute to the reproduction and experience of stigma, and linked to this, a sense of fatalistic acceptance of risk, which may become crucial in shaping health behaviour, including HIV prevention. Yet we also identify nonconforming cases of resistance to such oppression, characterised by strategies to preserve dignity and hope. This leads us to consider how hope for change provides an important resource of risk reduction as well as escape, if only temporarily, from the pervasiveness of social suffering."

"The joint UNODC/WHO/UNAIDS/World Bank estimate of the number of PWID worldwide in 2018 is 11.3 million (range: 8.9 million to 15.3 million), corresponding to 0.23 per cent (range: 0.18 to 0.31 per cent) of the population aged 15–64. This estimate is based on the most recent information available and assessment of the methodologies of the different sources.¹⁰⁸

"There is no change between the 2017 and 2018 estimates of PWID; however, any trend data must be viewed with caution, as methodologies may have changed. The 2018 global estimate of PWID is based on 122 countries, representing almost 90 per cent of the global population aged 15–64, compared with 110 countries in 2017. Of all the available sources in 2018, the estimates for at least 74 countries (61 per cent) were based on a “class A methodology” such as indirect prevalence estimation methods (e.g., the capture-recapture method, network scale-up method and multiplier method).¹⁰⁹

"Owing to the criminalization of drug use, punitive laws, stigma and discrimination against people who use or inject drugs in many parts of the world, conventional survey methods have been found to underestimate the actual population size because of the hidden nature of PWID;^{110, 111, 112} therefore, only indirect methods have been shown to reflect the situation of PWID with greater accuracy. Overall, new or updated estimates of PWID were available for 40 countries in 2018.

"Although the exact extent of injecting drug use is not known, estimates are more precise in some regions than others as a result of better data coverage and/or methodologies and the use of more recent data. Data on PWID vary between the regions in terms of coverage of the total population aged 15–64, with Asia having the highest coverage, at 95 per cent, and Africa having the lowest, at 68 per cent. At the subregional level, North America, South-West Asia, South Asia, Eastern Europe and South-Eastern Europe are fully covered, whereas data on PWID in the Caribbean only covers just over one third of the total population; therefore, data from that subregion must be interpreted with caution. Compared with 2017, coverage of the population in Africa increased substantially overall, from 58 to 68 per cent in 2018.

"The prevalence of PWID aged 15–64 in 2018 continues to be the highest in Eastern Europe (1.26 per cent) and Central Asia and Transcaucasia (0.63 per
cent). Those percentages are, respectively, 5.5 and 2.8 times higher than the global average. More than a quarter of all PWID reside in East and South-East
Asia, although the prevalence itself is relatively low (0.19 per cent). The three subregions with the largest numbers of PWID (East and South-East Asia, North America and Eastern Europe) together account for over half (58 per cent) of the global number of PWID. It is noteworthy that, as in previous years, while three countries – China, the Russian Federation and the United States – account for just 27 per cent of the global population aged 15–64, they are home to almost half (43 per cent) of all PWID."

"In particular, Russian law forbids substitution therapy for opioid dependence with methadone or buprenorphine. Naltrexone is the only specific pharmacotherapy that is currently approved for use in the Russian Federation and is available as an oral tablet in extended-release formulations."

"There were more than 240,000 drug crimes (acquisition, sale, manufacture etc.) registered by the Russian law enforcement agencies in 2006 - a 23 percent increase over 2005.
"Most of the crimes were committed in the large cities and industrial centres such as Moscow, St. Petersburg, Krasnodar, Kemerovo, Samara and Rostov. All these regions are located along the major drug trafficking routes.
"The number of crimes classified as “serious”and “extremely serious” has increased by 13 percent (from 134,988 cases in 2005 to 152,824 cases in 2006), although the overall number of drug crimes dropped by 5 percent (from 77 percent in 2005 to 72 percent in 2006). However, the definition of an “extremely serious crime” includes those cases where the offender has been arrested for possession of more than 2.5 grams of heroin.
"A similar trend is observed in drug trafficking cases where the number of these crimes increased by 12 percent in 2006 (100,000 cases in 2005 to 123,000 cases in 2006). However, in the context of all drug crimes, the proportion of drug trafficking cases actually declined by 5 percent (from 63 percent in 2005 to 58 percent in 2006)."

"Eighty-seven thousand people were arrested for drug related crimes in 2006 – an increase of 24 percent over 2005.
"The increase in arrests and the fact that more traffickers are being prosecuted suggests that the Russian law enforcement agencies are becoming more effective. It is certainly the case that they are carrying out more covert operations directed against organized criminal groups and drug trafficking networks."

"Street-level policing practices in Russia have been found to fuel a pervasive sense of risk, and fear of arrest, fine or detainment, among IDUs, which in turn is linked to their reluctance to carry needles and syringes, thereby increasing the chances of high risk syringe sharing at the point of drug sale (Rhodes et al., 2003). Police agencies themselves emphasise a rationale of intense surveillance of drug users, enforced through a combination of extremely restrictive criminal articles on possession and the use of administrative codes unrelated to drug use (Rhodes et al., 2003, 2006). Moreover, civil society responses to HIV prevention, treatment and care for IDUs remain weak, as does public health policy and infrastructure, which depends heavily upon international donation (Sarang et al., 2007; Wolfe, 2007). Officials and health professionals give very weak endorsement to concepts such as ‘harm reduction’, which are still characterised by some as a corrupting influence of the West, and instead defer to normative social constructions of drugs users as unproductive, dangerous, and criminal (Tkathchenko-Schmidt et al., 2008; Elovich and Drucker, 2008; Wolfe, 2007)."

As of September 1, 2018,, the Russian Federation's officially reported incarceration rate was 402 inmates per 100,000 of national population, with a reported total prison population of 582,889 out of an estimated national population of 144.9 million. In 2000, there were an estimated 1,060,404 people behind bars in Russia, for an incarceration rate of 729 per 100,000 of national population.

"Researchers have found that police harassment is one of the most important factors that exacerbate risky behavior among drug users in Russia. In a 2002 study of drug use in five Russian cities, 44 percent of drug users said they had been stopped by the police in the month prior to being interviewed, and two third of these said that their injecting equipment had been confiscated by the police. Over 40 percent added that they rarely carried syringes for fear of encountering the police with them. In the Togliatti study, Rhodes and colleagues found that fear of being arrested or detained by the police was the most important factor behind the decision of drug users not to carry syringes, which in turn was an important determinant of sharing syringes during injection. This study concluded that drug users who had been arrested or detained by the police for drug-related offenses were over four times more likely than other users to have shared syringes in the previous four weeks. Drug users who feared the police in Togliatti tended to avoid not only syringe exchange services but also drug stores that sold syringes because police frequently targeted people buying syringes at such locations, a result also highlighted in a 2003 study of drug users in Moscow."

"This was a couple of years after Russia had toughened its drug laws, lowering the minimum punishable dose to such a level that virtually any user could land behind bars. By 2004, the Justice Ministry estimated that 300,000 people were serving drug-related sentences in Russian prisons.
"That year the government -- responding in part to pressure from the Justice Ministry, which was fighting prison overpopulation -- raised the minimum punishable doses of illegal drugs, essentially ensuring that users who had no intent to sell would not be arrested. The police were incensed, arguing that some dealers took to carrying amounts just below the punishable level -- but still sufficient to satisfy between one and nine users. In other words, the police complained, they were being prevented from arresting users and small-time dealers and forced to focus on real drug dealers, whom they didn't want to touch with a 10-foot pole.
"The more-liberal policy lasted less than two years. The minimum punishable dose has been lowered again -- in most cases, by more than 50 percent. The dose is not quite as low as pre-2004 levels, but still low enough to put even casual users at risk."

"Being in prison or other state detention is an important risk factor for HIV in Russia. A very high percentage of drug users in the FSU [former Soviet Union] find themselves in state custody at some time in their lives. Injection drug use is reportedly widespread in Russian prisons, and HIV prevention services such as provision of sterile syringes, disinfectant materials for syringes and condoms are virtually absent. Official statistics indicate that from 1996 to 2003, HIV prevalence in Russian prisons rose more than thirty-fold from less than one per 1,000 inmates to 42.1 per 1,000 inmates. According to a 2002 report, about 34,000 HIV-positive persons—over 15 percent of the persons officially counted as HIV-positive in the country—were in state custody, of which the large majority found out about their HIV status in prison. The Kresty pretrial detention facility in Saint Petersburg was reported in 2002 to have about 1,000 HIV-positive persons among its 7,800 inmates. Some 300,000 prisoners are released each year from penal institutions in Russia, representing an important public health challenge."

"In 2010 an estimated 25 per cent of the 380 tons of heroin manufactured in Afghanistan -some 90 tons- was trafficked northwards through Central Asia via the Northern route and onward to the Russian Federation. The 90-ton total includes heroin consumed within Central Asia and the Russian Federation, as well as heroin seized by law enforcement or trafficked onward. More than three quarters of this amount are destined for the Russian market, with a small portion (approximately 3-4 tons) continuing to eastern and northern Europe.1 Furthermore, in 2010 between 35 and 40 tons of raw opium were trafficked through northern Afghanistan towards Central Asian markets. The entire 2010 opiate demand of the Northern route is required to transit or be produced in northern Afghanistan."

"In Central Asia, traffickers have access to a well-developed road and rail network. Around 70-75 per cent of opiates are transported by truck or another vehicle across Central Asia through Kazakhstan to major cities in south-western Russia and western Siberia.¹⁰⁸ Trains and planes usually account for approximately 15-25 per cent of trafficking. Seizures on trains have been on the rise as of 2011, particularly in Uzbekistan. Based on available data for Central Asia and Russia, in 2011 the average size of heroin seizures on trains was 6 kg, out of a reported 55 seizures (at the time of this writing). Shipments can, however, be much larger, as shown by two heroin seizures of 191 kg and 118 kg made in 2010 in the Russian Federation and Tajikistan, respectively."

"Russia remains a major destination country for Afghan opiates and other illicit drugs. According to a major Russian media report that cited official sources, Russia consumes between 75 and 80 metric tons (MT) of heroin each year. Illegal drugs are smuggled across Russia's Baltic and Black Sea ports and extensive land and rail routes.

"The amount of drugs seized by the Federal Drug Control Service (FSKN) increased from 24 MT in 2011 to 34 MT in 2012. FSKN seizures over the first six months of 2013 (18 MT) remained on pace to match or exceed 2012 totals. Significant interdictions included a 45 kilogram (kg) seizure of synthetic drugs in the Kurgan region and a 187 kg seizure of heroin in the Moscow region, estimated to be worth $180 million at street-value by FSKN."

"The widespread trafficking of cannabis continues unabated. The trafficking is fuelled by the fact that cannabis grows wild in a number of regions in Russia and so is readily available. Indeed, the Russian Federation and neighbouring Kazakhstan contain the world’s largest areas of wild cannabis and the Russian authorities estimate that production of wild cannabis in Russia is around one million (1,000,000) hectares. Depending on the climate conditions, one hectare of cannabis may produce up to 1 million seeds with 5-8 years of reproduction cycle. The THC content of cannabis differs in different regions but tends not to exceed 5 percent. Since 1992, cannabis seizures steadily increased 8 times and reached 89.7 tons in 2004. However, seizures sharply decreased almost threefold in 2005 (30.6 tons) and continued to decrease in 2006 (23.7 tons)."

"In the Russian Federation, decreased availability of heroin has led to its partial replacement with local and readily available substances such as acetylated opium, as in Belarus, and with desomorphine, a homemade preparation made from over-the-counter preparations containing codeine.⁴¹"

"The illicit manufacturing of synthetic drugs remains one of the major concerns. A thriving chemical industry, often lacking sufficient regulatory control, means that precursor chemicals are easily obtained by Russian criminals and are used in the production of synthetic drugs for both the domestic and foreign markets. The current trend seems to be that precursors used in the production of ATS are trafficked to European countries whilst precursors used in the production of heroin, are trafficked to Asia.
"In terms of domestic production, so-called “kitchen labs”, still prevail. The majority of these laboratories produce relatively small amounts of pervitine (ATS) for local consumption. This drug is widely abused and in terms of injecting users, is second only to heroin and other opiates.
"In 2006, there were 1,486 registered cases of illicit production of drugs (+14 percent compared to 2005). The main types of drugs illicitly produced in clandestine labs are amphetamines, methamphetamines, 3-methylfentanyl, and phencyclidine. It is rather reassuring to report that there are very few cases when illicit synthetic drugs were produced in laboratories at industrial facilities and most of the clandestine laboratories are either the “kitchen labs”, described above, or otherwise small scale, rudimentary enterprises."

"Russia has the largest population of injecting drug users (IDUs) in the world — an estimated 1·8 million people. More than a third have HIV; in some regions, the proportion is nearer to three-quarters. Astonishingly, an estimated 90% of Russian IDUs have hepatitis C, and most patients co-infected with HIV and tuberculosis in Russia are drug-dependent."

"In 2002, an estimated 93 percent of persons registered by the government as HIV positive since the beginning of the epidemic were injection drug users. In contrast, in 2002 an estimated 12 percent of new HIV transmission was sexual -- that figure climbed to 17.5 percent in the first half of 2003 -- indicating the foothold that the epidemic is gaining in the general population. The European Centre for the Epidemiological Monitoring of AIDS (EuroHIV), a center affiliated with the World Health Organization, noted that HIV prevalence may have 'reached saturation levels in at least some of the currently affected drug user populations' in eastern Europe, including in Russia, but cautioned against complacency 'as new outbreaks could still emerge among injection drug users…, particularly within the vast expanse of the Russian Federation.' Rhodes and colleagues in a February 2004 article echo this conclusion, noting evidence of recent examples of severe HIV outbreaks among drug users in Russia."

"There is no doubt that drug use and heroin use particularly have risen meteorically in Russia since 1990. Mikhailov said the total number of drug users had risen 900 percent in the decade ending in early 2004. A Max Planck Institute study of the drug trade in Russia concluded that drug-related crimes increased twelve-fold from 1990 to 1999. Many analysts have traced the dramatic rise in use of injected heroin since the fall of the Soviet Union to economic collapse and attendant rises in unemployment, poverty and desperation and to increased availability of cheap heroin trafficked through central Asia and across the former Soviet states. Some observers have suggested that the aftermath of the events of September 11, 2001 in Afghanistan and central Asia has done nothing to stem the flow of heroin through the region and may even exacerbate it in the long run. Mikhailov of the SDCC has told the press on numerous occasions that the United States military intervention in Afghanistan has contributed to heroin consumption in Russia because the Taliban had been able to suppress opium production before they were overthrown. In 2003, Victor Cherkesov, head of the SDCC, said the drug trade in Russia was valued at about U.S. $8 billion a year."

"The Russian Federation borders on a generalised epidemic with a population prevalence of 1.0% (95% CI 0.9% to 1.2%).² Official registration data from 2010 indicated over 38 000 prevalent cases in Moscow,³ the largest city of the Federation and the political and economic hub. The continued rise of HIV parallels the increase in sexually transmitted infections (STIs), most notably syphilis and Chlamydia, in the years following the fall of the Soviet Union,^{4 5} which subsequently stabilised to approximately 78.5 and 100.8 per 100 000, respectively, by 2004.⁶
"Russia’s epidemic is largely concentrated among vulnerable populations.^{2 7} Injection drug use (IDU), responsible for over half of all new infections, has been considered the primary driver.⁸ Sexual transmission is increasingly common and contributes approximately one-third of new HIV cases.^{8 9}

"There is some controversy over the number of narcotic drug users in Russia. Dr. Vadim Pokrovsky of the Federal AIDS Center said that estimates of the number of active drug users in Russia in February 2004 ranged from 1 to 4 million, and he believed the high end of that range reflected the reality. On February 20, 2004, Alexander Mikhailov, the deputy director of the State Drug Control Committee (SDCC), a federal body, was cited in Pravda as saying that Russia had over 4 million drug users, and that the "gloomy prediction" of his office was that Russia could have over 35 million drug users by 2014. In early January 2004, the executive secretary of the Commonwealth of Independent States, which includes twelve former Soviet states, predicted that in 2010 the twelve countries would have 25 million drug users of whom 10 million would be living with HIV/AIDS, the vast majority in Russia."

"By far the highest prevalence of HIV among PWID [People Who Inject Drugs] is in South-West Asia and in Eastern and South-Eastern Europe, with rates that are, respectively, 2.4 and 1.9 times the global average. Together, those two subregions account for 49 per cent of the total number of PWID worldwide living with HIV. Although the prevalence of HIV among PWID in East and South-East Asia is below the global average, 24 per cent of the global total of PWID living with HIV reside in that subregion. An estimated 53 per cent of PWID living with HIV worldwide in 2016 (662,000 people) resided in just three countries (China, Pakistan and the Russian Federation), which is disproportionately large compared with the percentage of the world’s PWID living in those three countries (35 per cent)."

"In Russia, substitution therapy is forbidden by law, and naltrexone is the only available pharmacotherapy for heroin dependence. Due to the lack of alternatives to naltrexone and stronger family control of compliance (adherence), naltrexone is more effective for relapse prevention and abstinence stabilization in Russia than in Western countries. Long-acting, sustained-release formulations (injectable and implantable) seem particularly effective compared with oral formulations."

"With a net profit of US$ 1.4 billion from the heroin trade alone, in 2010 drug traffickers earned the equivalent of a third of the GDP of Tajikistan (US$ 4.58 billion) or Kyrgyzstan,²⁶⁹ but only 5 per cent that of Uzbekistan (US$ 28 billion) and 1 per cent of that of Kazakhstan. The economies of Kyrgyzstan and Tajikistan appear to be the most vulnerable in Central Asia, while in Kazakhstan the entire amount would constitute a very small part of total economic activity."

"Studies conducted in St. Petersburg, Russia, for more than a decade have demonstrated the efficacy and safety of different naltrexone formulations (oral, implantable, injectable) for relapse prevention and maintenance of abstinence in detoxified opioid addicts. The positive results from different formulations seem related to two cultural factors. One is that relatives can be recruited to supervise daily dosing of the oral formulation. However, this advantage is decreasing as the addicted population ages. The second is that substitution therapy is not available; thus, naltrexone is the only effective medication available, which makes it easier to motivate patients to use it. Preliminary findings from studies of long-acting, slow-release formulations of naltrexone (implantable and injectable) suggest that they are more effective than the oral formulations and are likely to be important additions to current treatments. How they compare with maintenance treatment using methadone or buprenorphine in settings in which these three treatment options are available is a topic for future studies."

"A dynamic model of HIV transmission among people who inject drugs in Russia suggests that assuming a baseline HIV prevalence of 15%, increasing coverage of OST from 0% to 25% of all people who inject drugs could decrease HIV incidence by between 44% and 53%¹⁰⁸."

"More than half of all cases are related to drug possession with no intent to supply, which refers primarily to people who use drugs rather than traffickers. This highlights the fact that Russia prioritizes punishment of people who use drugs in its war against illegal drugs, a situation further underscored by the following:

"• In 2010 about 108,000 people were convicted for drug crimes (under Articles 228–233 of the Criminal Code)³⁰; of them, nearly two-thirds (no fewer than 64.7%) were convicted for drug possession with no intent to supply³¹. More than 104,000 people were charged with fines and administrative arrest for mere drug use or possession of drugs in tiny amounts (e.g., 0.5 grams of heroin or less).³²

"• Russian laws define 'large' and 'extra large' amounts of drugs to be much lower than the average quantity necessary for daily use. That is because for some narcotic drugs, such as heroin, marijuana or methadone³³, the 'large' and 'extra large' amounts are determined not by the weight of the pure substance but by the weight of the entire mixture seized³⁴."

"Money laundering continues to cost the Russian economy billions of dollars every year. In 2012, the Central Bank of Russia (CBR) estimated that $49 billion left Russia illegally. Of this, $35 billion left Russia through what the CBR terms 'fictitious transactions,' which according to the CBR includes payment for narcotics, bribes to government officials, and tax evasion. While there has been significant progress in improving Russia's AML/CFT legal and enforcement framework, the prevalence of money laundering in Russia remains a major obstacle to financial sector development. Domestic sources of laundered funds include organized crime, evasion of tax and customs duties, fraud, smuggling operations, and corruption.

"Official corruption remains a major problem at all levels of government. Despite several recent high profile anti-corruption actions by the Government of Russia, corruption is a major source of laundered funds, with proceeds frequently moved offshore.

"Russia is considered a significant transit and destination country for international narcotics traffickers; criminal elements from Russia and neighboring countries continue to use Russia's financial system and foreign legal entities to launder money. Criminals invest and launder their proceeds in securities instruments, both domestic and foreign real estate, and luxury consumer goods."

"In 2010 alone, the prosecution of drug offenders (for use and supply) cost at least $100 million in Russia. In comparison, under the Budget Law for 2011, HIV prevention programming is to receive less than 3% of the total $640 million to be allocated in 2012 through the Federal Budget Law for HIV, hepatitis B and C, and the government continues to prohibit internationally accepted drug treatment interventions such as OST [Opioid Substitution Treatment]. The government therefore will spend millions more treating people infected with HIV than it would have in protecting their health and reducing transmission."

"It is important to note that profits made from trafficking Afghan opiates into Central Asia (USD 344 million) in 2010 are dwarfed by the net profit pocketed by criminals trafficking onwards to the Russian Federation, which was around US$ 1.4 billion in 2010. This calculation does not include other drugs such as those of the cannabis group, which are also trafficked through the region.
"The mark-up on heroin brought into Central Asia and sold in the Russian Federation is as much as 600 per cent. As shown in the figure below, as prices increase purity decreases; this is explained by the growing distance from the source and by the practise of cutting the heroin with adulterants. This means that 1 kg of heroin at 70 per cent purity can become 2 kg at 35 per cent purity. This inversely proportional relationship between price increase and decrease in quality translates into greater profits for traffickers."

"It is important to note that Russian law enforcement agencies—including the Federal Drug Control Service (FDCS), which has an annual budget of $73 million35—often use drug charges as a way to silence political opponents, including human rights activists and journalists. A few examples:

"• Since August 2011 Russian law enforcement agencies have been trying to suppress activities of the Andrey Rylkov Foundation (ARF), an organization that promotes and defends human rights of people who use drugs in Russia. First, ARF activist Irina Teplinskaya was planted with a tablet of methadone when she crossed the border from Ukraine to Russia in August 2011. Then in early 2012 the ARF website was shut down by the FDCS, which claimed that the information about OST posted on the ARF website should be categorized as drug propaganda, and thus prohibited under Russian drug laws³⁶.

"• Political activists Taisiya Osipova was prosecuted based on falsified drug charges by an anti-extremist police unit. In December 2011, despite obvious violations of procedural and substantial laws, Osipova was sentenced to 10 years in prison³⁷.

"• In April 2011 Evgeny Konyshev was planted with drugs by representatives of the 'City Without Drugs' Foundation after he openly testified on a federal TV channel about the Foundation’s ineffective and inhumane practices under the pretence of drug treatment. Despite multiple violations of procedural and substantial laws committed during the pre-trial investigation, by the end of February 2012 Konyshev remained in pre-trial detention facing a charge of possession of 'extra large' quantity of heroin (2.72 grams) with no intent to sell³⁸.

"• In 2010 anticorruption activist Denis Matveev was sentenced to six years imprisonment based on false accusation of drug trafficking after he reported corruption in his city involving police officers and members of the mayor’s office³⁹."

"In the last three to five years an increasing number of reports suggest that people who inject drugs (PWID) in Russia, Ukraine and other countries are no longer using poppies or raw opium as their starting material, but turning to over-the-counter medications that contain codeine (e.g. Solpadeine, Codterpin or Codelac). Codeine is reportedly converted into desomorphine (UNODC, 2012; Gahr et al., 2012a, 2012b, 2012c; Skowronek, Celinski, & Chowaniec, 2012). The drug is called Russian Magic, referring to its potential for short lasting opioid intoxication or, more common, to its street name, krokodil. Krokodil refers both to chlorocodide, a codeine derivate, and to the excessive harms reported, such as the scale-like and discolored (green, black) skin of its users, resulting from large area skin infections and ulcers. At this point, Russia and Ukraine seem to be the countries most affected by the use of krokodil, but Georgia (Piralishvili, Gamkrelidze, Nikolaishvili, & Chavchanidze, 2013) and Kazakhstan (Ibragimov & Latypov, 2012; Yusopov et al., 2012) have reported krokodil use and related injuries as well."

"In considering the drug krokodil, two aspects are of importance, its pharmacology and its chemistry. The short half-life, limited high after the impact effect and, in particular the need for frequent administration may narrow the attention of users on the (circular) process of acquiring, preparing and administering the drug, leaving little time for matters other than avoiding withdrawal and chasing high, as reported in several popular magazines (e.g. Shuster, 2011; Walker, 2011). However, when the layers of bootleg chemistry and attribution are peeled off, what’s left is an opioid analogue (or several ones) that, besides the variations in half-life, behaves pharmacologically not very different than heroin or Hanka (Haemmig, 2011). There are various paths to synthesize desomorphine from codeine, but the chemical process most commonly reported to be used by PWID in Russia and Ukraine is very similar to that of home-produced methamphetamine or Vint (Grund, Zábransky, Irwin, & Heimer, 2009; Zábransky, 2007) – a rudimentary version of a simple chemical reduction. The illicit production of krokodil reportedly involves the processing of codeine into the opiate analogue desomorphine (UNODC, 2012; Gahr et al., 2012a, 2012b, 2012c; Skowronek et al., 2012). Desomorphine (Dihydrodesoxymorphine-D or PermonidTM ) is an opiate analogue first synthesized by Small in 1932 (Small, Yuen, & Eilers, 1933). The analgesic effect of desomorphine is about ten times greater than that of morphine (and thus stronger than heroin), whereas its toxicity exceeds that of morphine by about three times (Weill & Weiss, 1951). The drug’s onset is described as very rapid but its action is of short duration, which may lead to rapid physical dependence and frequent administration."

"In recent years, harm reduction and drug treatment services from Russia, Ukraine, Georgia and Kazakhstan began reporting severe health consequences associated with krokodil injecting. Although serious localized and systemic harms have previously been associated with injecting homemade opiates and stimulants in the region (Grund, 2002; Volik, 2008), the harms associated with krokodil injecting are extreme and unprecedented. The most common complications of krokodil appear to be serious venous damage and skin and soft tissue infections, rapidly followed by necrosis and gangrene (Gahr et al., 2012a, 2012b, 2012c; Skowronek et al., 2012). Our research further identified an impressive, undoubtedly incomplete, list of injuries and symptoms (Table 1), reported in the media (e.g. Shuster, 2011; Walker, 2011) and identified in YouTube clips and photographs on the internet. Importantly, this list includes several parts of the body that are not typically used as sites for injecting drugs. This suggests that the ill effects of krokodil are not limited to localized injuries, but spread throughout the body (Shuster, 2011; UNODC, 2012), with neurological, endocrine and organ damage associated with chemicals and heavy metals common to krokodil production (Lisitsyn, 2010).
"It is important to note that the described harms seem to become manifest relatively shortly after krokodil injecting is initiated. Present accounts of krokodil related harms often concern young people presenting in emergency rooms and surgeries with extreme and advanced complications. According to NGOs that work with people who inject krokodil, these young people have relatively short histories of using the drug. Mortality rates among young krokodil users are reportedly high (Akhmedova, 2012; Shuster, 2011; Walker, 2011), with official reports associating krokodil use with half of all drug-related deaths in at least two Oblasts (Walker, 2011)."

"The estimated number of PWID in Russia was close to 2 million in 2008 (Mathers et al., 2008). 2.3% of the Russian population uses opioids annually and 1.4% heroin, compared to an annual prevalence of 0.4% opioid use in Western and Central Europe (UNODC, 2012). While actual epidemiological data is not available, a number of academic and media reports suggest that 5% or more of Russian drug users (approximately 100,000 PWID) may be injecting krokodil (Walker, 2011), while 'various official estimates' place the numbers of Russian PWID using krokodil as high as one million (Shuster, 2011). Epidemiological data is critical to evaluating claims that the use of krokodil is reaching epidemic proportions in Russia (Walker, 2011), and potentially, the Ukraine. There are an estimated 290,000 to 375,000 PWID in Ukraine (Mathers et al., 2008). A recent national survey found that 7% of PWID have used krokodil in 2011 (Balakireva, 2012), suggesting that around 20,000 PWID in Ukraine may have used krokodil that year. Balakireva and colleagues furthermore found statistically significant differences in krokodil use between the cities in the study, with most krokodil use reported in Uzhhorod (35.6%), Simferopol (26.9%), Kyiv (21.7%), Chernivtsi (15.5%) and Donetsk (12.6%). Estimates from other countries are not available. Outside of the former Soviet region, krokodil has been reported in Germany (Der Spiegel, 2011) and in Tromsø in northern Norway (Lindblad, 2012)."

"In sum, these observations suggest that the relatively limited availability of black market opiates and stimulants and the relative ease of harvesting legal precursors to powerful analogues from the countryside and pharmacies inspired and sustained a Soviet-style homemade drug culture in the Eastern European region that remains radically different from those observed in countries where narco-traffickers dominate the production and distribution of drugs (Booth, Kennedy, Brewster, & Semerik, 2003; Grund et al., 2009; Grund, 2005; Subata & Tsukanov, 1999; Zábransky, 2007).
"The physical and logistical exigencies of home production; its locus in networks of drug injecting friends and the high degree of cooperative action involved (in foraging for, producing and using the drugs); the multiple roles and ambiguous status of injecting paraphernalia; the routine occurrence of well-known risk behaviours (e.g. syringe sharing, frontloading) and those currently less well understood, such as the slapdash nature of the bootleg drug synthesis and its unpredictable outcomes in terms of actual drug product, purity and pollution— indeed all of these factors contribute to and interact within the vastly complex high risk environment of home drug production in the region."

"In Russia and many other post-Soviet countries, the old ideology lingers on in narcological institutes, out of sync with modern public and mental health concepts (Grund et al., 2009). Many narcologists continue to view addiction as criminal or moral deviance and not as a disease. Narcological dispensaries continue to share information with law enforcement (Mendelevich, 2011). The threat of removal of child custody rights may impede women’s access to health care in particular (Shields, 2009). Stigma and discrimination, hostile treatment and lack of confidentiality are persistent in the treatment of PWID and must be viewed as important barriers to timely seeking medical care (Beardsley & Latypov, 2012; Mendelevich, 2011; Wolfe et al., 2010). PWID have therefore strong incentives to avoid narcological facilities and, by association, other state health services. In their personal 'hierarchy of risk,' seeking help for significant health problems is subordinated by the need to stay under the radar of the authorities (Connors, 1992). Several of the YouTube clips on the internet furthermore document not only the gravity of harms among krokodil users, but also poor and inhumane treatment of those hospitalized with krokodil related injuries. In one video a man’s leg is sawn off under the knee with a lint saw in what seems not to be a surgical unit, but perhaps a common hospital ward. The man sits wide-awake in an ordinary wheelchair and holds his leg himself above a bucket, which was lined with a garbage bag just before. These videos and case reports (Asaeva et al., 2011; Daria Ocheret, personal communication, 2012; Sarah Evans, personal communication, 2012) suggest that the care provided to those with krokodil related injuries may be (grossly) substandard, sometimes exacerbated by improper diagnosis and faulty clinical decisions."

"In June 2012, the government launched the 'State Counternarcotics Strategy until 2020' that calls all agencies and all levels of government to join in the fight against illicit drugs. The Strategy urges improvements in supply and demand reduction, and outlines new legislation aimed at deterring drug trafficking. An important development in implementing the Strategy in 2012 was the signing in March by then-President Medvedev of a law stipulating life sentences for trafficking large quantities of drugs. Previously, the maximum sentence was 20 years. The law also allows for the confiscation of property and money obtained by drug dealing."

"The MVD and the Federal Security Service (FSB) are Russia’s two federal agencies responsible for drug-related investigations.  Minister of Internal Affairs Vladimir Kolokoltsev is the Chair of the State Anti-Drug Committee, which coordinates Russia’s drug control policy.  The Ministry of Health is the primary government body responsible for drug user rehabilitation.  The Ministry of Health, Ministry of Education, MVD, and a number of other agencies and public organizations administer drug abuse prevention programs."

"The system of penalties for juveniles facing criminal charges in Russia is based on suspended sentences or detention in educational correctional facilities, which house young offenders aged up to 21 years. The average sentence is four years. Only one quarter of adult recidivists considered a high-risk to society are said to have been admitted to a VK [educational correctional facilities] as juveniles."

"Although in Russia drug use per se is not criminalized as in Georgia, possession without intent to supply in amounts exceeding 0.5 grams for heroin, opium or desomorphine is considered a crime and is punished by incarceration for up to three years²⁷. At the same time it is important to emphasize that even where drug use is not a criminal offence, most countries apply administrative liability for it; in Russia, drug use can therefore result in 15 days arrest, which according to the European Court on Human Rights is equal to criminal liability.

"Experts estimate that in 2010 alone, prosecution for all drug offenders (demand and supply) cost an estimated $100 million in Russia²⁸. That amount covers most expenses from the moment of arrest to the court decision, including those associated with operational-search measures, detention, preliminary investigation and court appearances (including payment for lawyers). It does not include the costs of pre-trial detention, incarceration after conviction or executing non-custodial sanctions, such as community service, fines, etc.²⁹

"More than half of all cases are related to drug possession with no intent to supply, which refers primarily to people who use drugs rather than traffickers. This highlights the fact that Russia prioritizes punishment of people who use drugs in its war against illegal drugs, a situation further underscored by the following:

"• In 2010 about 108,000 people were convicted for drug crimes (under Articles 228–233 of the Criminal Code)³⁰; of them, nearly two-thirds (no fewer than 64.7%) were convicted for drug possession with no intent to supply³¹. More than 104,000 people were charged with fines and administrative arrest for mere drug use or possession of drugs in tiny amounts (e.g., 0.5 grams of heroin or less).

"• Russian laws define “large” and “extra large” amounts of drugs to be much lower than the average quantity necessary for daily use. That is because for some narcotic drugs, such as heroin, marijuana or methadone³³, the “large” and “extra large” amounts are determined not by the weight of the pure substance but by the weight of the entire mixture seized³⁴."

"Substitution (or replacement) therapy such as methadone maintenance therapy, which has been widely credited with controlling HIV transmission among injection drug users in many countries, is illegal in Russia, and the 2003 amendments to the drug law did not change this. Methadone is classified as "illicit" by the terms of the three United Nations conventions on drug control, though most countries that are signatories to the conventions have methadone programs that are successful in substituting injected heroin with noninjected methadone. In this case, neither the SDCC [State Drug Control Committee] nor the Ministry of Health seems necessarily disposed to review the status quo. Dr. Golyusov of the Ministry of Health said that he is concerned by first-hand accounts from drug users that methadone is more addictive or "harder to get off" than heroin and that other countries' experiences have been "contradictory.""

"Russia has a legislative and financial monitoring structure that facilitates the tracking, seizure, and forfeiture of all criminal proceeds. Russian legislation provides for investigative techniques such as wiretapping, search, seizure and the compulsory production of documents. Legislation passed in 2004, entitled: "On Protection of Victims, Witnesses and Other Participants in Criminal Proceedings" extends legal protection to all parties involved in a criminal trial. Prosecutors or investigators may recommend that a judge implement witness protection measures if they learn of a threat to the life or property of a participant in a trial."

"Because of drug laws that have historically criminalized the possession of very small amounts of narcotics, drug users in Russia face a high probability of spending time in prison or pretrial detention at some time in their lives. Injection drug use is widespread in prisons. But basic HIV prevention measures, including condoms and materials for sterilization of syringes, are largely lacking in Russian correctional facilities, making prisons across the country high-risk environments for AIDS. The vast numbers of prisoners released every year thus represent a public health challenge for the general population. Both in and outside of prison, the virtual absence of humane services to treat drug addiction and the illegality in Russia of methadone and other drugs used elsewhere to treat heroin addiction further compromise HIV prevention among drug users."

"The main reasons cited for restricting the opportunity of drug users to obtain medical and social aid, including prevention services, are the legislative barriers and official policy course that emphasizes reducing supply through law enforcement and reducing demand by promotion of 'healthy lifestyle'. The Strategy of the Anti-Narcotic Policy of the Russian Federation until 2020⁶¹ and the plan to implement the strategy reaffirmed that approach. The 10-year plan restricts all activities and advocacy associated with harm reduction and other evidence-based services for people who use drugs. OST [Opioid Substitution Treatment] and NSPs [Needle and Syringe Exchange Programs] are considered antithetical to the strategy because they are 'attempts to legalize substitution therapy with use of narcotic drugs and promotion of drug use under pretext of syringe replacement'. Non-governmental organizations (NGOs) are prohibited from providing information on OST and other treatment and prevention measures opposed by the government. Such restrictive policies clearly indicate that the punishment and social isolation of people who inject drugs is the basis of state’s strategic approach to drug demand reduction. These policies have high financial and social costs."

"State action that impedes people from protecting themselves from a deadly epidemic is blatant interference with the right of Russians to the highest obtainable standard of health. There is no dispute as to the effectiveness of sterile syringes for preventing HIV, hepatitis C and other blood-borne infections. Public health experts are virtually unanimous in the view that providing access to sterile syringes neither encourages drug use nor dissuades drug users from entering drug treatment programs. In reality, the near absence of humane treatment programs for drug addiction in Russia and the very nature of drug use guarantee that there will always be people who either cannot or will not stop using drugs. Impeding this population from obtaining or using sterile syringes amounts to prescribing death as a punishment for illicit drug use."

"The drug enforcement agencies are supported in their functions by strong drug control laws and high-level Governmental attention. While recent years have seen some increase in the resources devoted to the prevention of drug abuse and to the care for drug users, the major emphasis in the Government's policy is clearly targeted on addressing the problem of drug trafficking and production.
"Some outside observers believe that this heavy emphasis on law enforcement sometimes hampers efforts to address the problems of drug abuse, particularly among the youth. For one thing, there is some evidence that many drug users are sent to prison for drug trafficking, although they are arrested with small quantities of drugs in their possession. Since 1997, with the introduction of a new Criminal Code, the possession of a "small amount of narcotics" is not considered a criminal offence, but an administrative infraction. However, the definitions of what constitutes a "small amount" of the various drugs are established at extremely low levels. In the case of heroin, there is no quantity that can be considered a "small amount" and, thus, the possession of any quantity of that drug can be prosecuted as drug trafficking. This phenomenon, coupled with the fact that there are no juvenile courts in Russia, has resulted in the incarceration of many young drug users in adult prisons where there are few, if any, drug treatment programmes, and where they may be exposed to risks of violence, and of infection with tuberculosis and HIV/AIDS."

"Russia now has a 1 percent HIV prevalence rate among its young people and the fastest growing HIV/AIDS epidemic in the world. While the epidemic is still predominantly fuelled by injecting drug users and confined to their ranks, there are clear signs that the epidemic continues to spread to the general population, especially the youth."

"The epidemic disproportionately affects IDUs who comprise 87% of the cumulative number of registered HIV cases, however, with the epidemic becoming more mature, the infection tendency away from IDUs to heterosexual is also increasing with 68% of newly registered cases by the end of 2004 corresponding to IDU and 30% to heterosexuals (In the previous year heterosexual transmission accounted for 23.4% of new infections). The interpretation of the tendency towards less new infections diagnosed is not an indication of a slowing of the epidemic but rather reflective of the changes in HIV testing policy, the smaller number of tests performed in population groups with high-risk behaviors and also a shortage of test kits."