How War Worsened Opioid Crisis In Ukraine

The Alliance for Public Health's outreach vans provide harm reduction services and humanitarian aid throughout Ukraine. Photo: Alliance for Public Health

Medications to treat opioid use disorder, including methadone and buprenorphine, have been shown to save lives, cutting overdose deaths by up to 60% and reducing the transmission of HIV by offering a safe alternative to injection drug use. Many patients take these medications, which are called opioid agonist therapies, for years or even decades, and may be at risk of overdose if they lose access to treatment.

In Ukraine, which has the highest prevalence of HIV in Europe, war and the resulting disruptions to medical care have created a crisis for patients with drug use disorder and those who treat them.

Two years after Russia's full-scale invasion of Ukraine, which began on February 24, 2022, a new study published in Journal of Substance Abuse Treatment examines how opioid treatment programs were interrupted by Russia's 2014 invasion of the east of Ukraine and Crimea. Led by Anna Meteliuk, a research project manager at the Alliance for Public Health in Kyiv, Ukraine, and Danielle Ompad, vice dean for academic affairs and professor of epidemiology at the NYU School of Global Public Health, the study found that, despite efforts of local public health programs, only one-fifth of patients living in the areas occupied by Russia were successfully referred to drug treatment sites in non-conflict areas of Ukraine.

The researchers also looked at whether patients who transferred to other programs stayed in them long term. They found that less than half of the patients continued treatment through 2021, although those who received higher doses and more flexible methods of dosing were more likely to stick with their medications.

"We know from the United Nations that dozens of people in Crimea died of overdoses in the first six months after the invasion because they no longer had access to treatment under Russia's restrictive drug laws. Our study provides further evidence of how challenging it has been to ensure access to life-saving opioid treatments in Ukraine," said Ompad, who is also the deputy director of the Center for Drug Use and HIV/HCV Research (CDUHR) at the NYU School of Global Public Health.

Can you describe the need for drug treatment and harm reduction services in Ukraine?

Meteliuk: Ukraine's high rate of HIV is mostly driven by injection drug use. We had a huge epidemic of opioid drug use in Ukraine after the Soviet Union collapsed in 1991. Ukraine was in the middle of drug trafficking routes from Afghanistan to European countries, but lots of drugs stayed in the country, leading to a dramatic increase in opioids and injection drug use.

Before the 2014 conflict, the Donbas area-which is the Donetsk and Luhansk regions-and Crimea were responsible for almost one-third of all patients taking opioid agonist therapies in Ukraine. Those are highly drug-using regions because they border Russia, and at that time, most of the drugs we had in the country were coming from Russia. So those areas were responsible for a large share of opioid treatment patients in general.

Ompad: There's a very strong harm reduction infrastructure throughout Ukraine. Organizations like Anna's, the Alliance for Public Health, provide HIV testing and other harm reduction supplies, including needle exchange and condoms. And they've been working the whole time during the conflict. We cannot underestimate the dedication of public health workers and harm reduction specialists.

What has been most disruptive for opioid treatment in Ukraine? Supply issues? The destruction of treatment sites? Displacement of residents?

Meteliuk: It's all of those things, but the major way opioid treatment is disrupted is because Russia is occupying areas. There is no methadone in Russia-opioid agonist therapies are prohibited. That's why, once they take over a town that has a treatment site, it gets closed right away because it's not allowed. If patients stay in that area, they may go back to street drugs or overdose and die. But if they leave for another part of Ukraine, they can be transferred to another treatment site.

Ompad: When Russia invaded Ukraine for the first time and occupied Crimea, the Russian drug czar came on TV and said that they're going to get rid of opioid agonist therapies in Crimea. People were kicked off treatment almost immediately, and there were documented overdoses because they left people without the support they needed.

What are your study's implications for the current conflict in Ukraine?

Meteliuk: This study teaches us a lesson of how to act in the current situation. When Russia invaded us again in February 2022, they occupied the whole Luhansk region, so the opioid treatment program in Luhansk completely closed. Most of the sites in Donetsk and areas in Zaporizhzhia closed as well. Russia also took Kherson, but we got it back and reopened the treatment program. So once our army frees any territory, sites are being reopened.

We've also had 17 sites ruined by shelling. But again, those of us at the front-lines, public health and the government and other non-government organizations, we are renovating and reopening sites. And if a site is destroyed, it doesn't mean that patients don't have anywhere to go; they are redirected to another site that is close to them.

After the 2014 invasion, there was internal displacement, but after the full-scale invasion in 2022, many people moved abroad. The Alliance, together with the Ministry of Health of Ukraine, created a list of opioid treatment sites in neighboring countries where people were potentially going-Poland, Moldova, Romania, Germany-and we contacted providers in those countries. This way, if someone came to his Ukrainian doctor saying, "Tomorrow, I'm going to Poland," for example, he will get his 15 day supply, and get all the documentation translated into English and the contact of where to go in Poland to get his medication. Once the person gets to Poland, he goes to that medical facility and gets the same dosing of methadone that he was taking in Ukrain

Has the war forced any changes to substance use treatment that have improved access to care?

Meteliuk: The war created a very strong network of what we call "narcologists," or drug treatment specialists. We have different chats and groups for exchanging information. For example, if a client from an occupied area is going to a non-occupied area, a doctor may call and say, "This person is going to be at your place in three days." They're being taken care of.

There's also more flexibility in take-home doses. It used to be that a person had to come to a site every day to receive medication. Then COVID started in 2020, and our government issued interim guidelines which allowed for a 15- to 30-day supply. It proved to be effective in certain cohorts of patients, like those who are stable, who are employed, who have families.

Once the war started, we were still using those guidelines, so the government allowed 30-day supplies, especially in very affected regions in the east and south. We've now moved back to 7-day, 10-day, and 15-day supplies, depending on the patient. We are also piloting the use of telemedicine.

Ompad: Something similar happened in the U.S. during COVID. SAMHSA [The Substance Abuse and Mental Health Services Administration] changed our guidelines to allow more take-home doses, as well as telemedicine. A lot of people are advocating for that flexibility to stay in the regulations.

What questions remain unanswered about treatment during the current conflict?

Meteliuk: Our next plan within this study is to see what happened to patients who are living with HIV, and whether their ART [antiretroviral therapy HIV treatment] was interrupted or not.

Ompad: Something that I would like to know that is not easy to get at right now is what happened to the people who didn't re-enroll in treatment programs. How many of those people survived, and how did they survive? What happened with their opioid use? How many overdosed? How many were caught up in the conflict? It's a highly vulnerable community and it would be really important to understand these things so that we can figure out how to maintain continuity of care.

The research was supported by the Ukraine HIV Research Training Program, which is funded by the National Institutes of Health's Fogarty International Center (D43TW010562), as well as National Institute on Drug Abuse funding to CDUHR (P30DA011041).