When the cure is worse than the disease

Tuesday discussions (as well as debates, journal fixes and lectures) at the Sakharov Center are a venerable and well-established tradition by today’s standards. For three years now, every week, leading historians and economists, journalists and civil activists, ecologists and political scientists, writers and filmmakers discuss with each other, as well as with the interested public, important, topical, topical, acute, painful issues.

Sometimes painful in the literal sense of the word: the subject of discussion last week was the pain to which the impossible rules for the dispensing of narcotic drugs in our country doom those dying from cancer. All this, of course, under the noble slogans of the fight against drug addiction and with the connivance of society.

The conversation turned out to be gloomy and not encouraging: the experts agreed that both the internal logic of the ideology of the “war on drugs” and the logic of departmental thinking will not allow seemingly simple amendments to be made to bureaucratic procedures in the foreseeable future.

We are publishing a brief retelling of this discussion, in which the following took part: Vasily Vlasov - Doctor of Medical Sciences, Professor, President of the Society of Evidence-Based Medicine Specialists; Konstantin Ksenofontov - editor of the portal InLiberty.ru; Stanislav Lvovsky - poet, publicist, editor of the portal Colta.ru; and Arseny Pavlovsky - psychologist, expert at the Andrei Rylkov Charitable Foundation for the Promotion of Health and Social Justice. The discussion was moderated by the director of the Sakharov Center, Sergei Lukashevsky.

Lukashevsky. I was trying to find an analogue to the problem of drugs and the fight against them, and the story of terrorism came to mind. Drug addiction, like terrorism, is evil. But as we know, the fight against terrorism produces unwanted, cruel and tragic side effects. Because when humanity designates something as an absolute, main evil, then anything can be justified by fighting it.

There are two approaches, two paradigms in the fight against drugs. The first is “war”, the emphasis on punitive measures adopted in Russia and, for example, in the USA, the second is harm reduction, which is what Europe is focusing on. But, as usual, we also have “aggravating circumstances”: I don’t know if there is at least one other country in the world where the anti-drug agency is formed by former tax police officers, and entrepreneurs selling confectionery poppy seeds are imprisoned as drug dealers. And, of course, no matter how severe the anti-drug legislation in other countries, it does not interfere with prescribing pain relief to patients who are no longer helped by anything other than opiates.

Vlasov. The very word “drugs” encourages a simplified understanding of the problem and, therefore, carries the temptation of simple solutions. In fact, addiction is caused not only by substances traditionally called drugs, but also, in particular, by many medications, including those for which demand is fueled by medical fashion, such as the American fashion for ADHD (adolescent Attention Deficit Disorder). hyperactivity"), which is treated pharmacologically.

In archaic societies, psychoactive substances - such as opium or coca leaves - have been used for centuries. But, being borrowed by modern culture, they have become a serious problem. And, as a result, the fight against them became a problem. There is no simple solution here. You just need to understand: “what is a problem for a German is a disaster for a Russian”: the “war on drugs” in Russia resulted in a terrible bureaucratic process that did not help drug addicts in any way, but doomed those who really need opiates to torment.

Here two soft but terribly strong waves collided. The first is the weakness and “civil impotence” of doctors: doctors are not fighters. They sympathize with their patients, but will not fight against the system. And the second wave is the cynical stupidity of the drug control authorities. And until forces capable of big changes appear in our society, we will continue to struggle with veterinarians and grandmothers who have poppies growing in their front garden.

Xenophon. Some psychoactive substances are prohibited, while others are not, only due to historical accidents, because it is impossible to find logic here. The total harm of certain substances is assessed according to three parameters: addictiveness, social danger of a person under the influence of a drug or in search of money for a dose, and harm to health. About five years ago, a study was published in the Lancet journal, the authors of which ranked different substances according to the “sum” of these three parameters - and came to the conclusion that completely legal alcohol and tobacco are second in total harm only to opiates and methamphetamine (“vintu”) and are approximately on par with cocaine.

Therefore, the “drug problem” actually concerns only a few substances. Speaking about its decisions, one cannot fail to take into account the experience of two European countries where drugs were decriminalized (decriminalization does not mean legalization: detected drugs are confiscated, dealers are fined, but not imprisoned). These are Portugal (2006) and the Czech Republic (2010). The results in Portugal can already be judged: the number of drug addicts has not changed at all, and the number of people who have tried it has increased slightly in some age groups, and slightly decreased in others. In other words, the only result of drug decriminalization is that a certain number of people did not go to prison and did not undergo “prison socialization.”

Lvovsky. Today's Russia is a society of people with reduced empathy and the ability to compassion. However, the reasons for the inaccessibility of pain relief are simpler and more banal: all drug policy in the country is at the mercy of the security forces. And the intelligence services, regardless of what they do, always have the same logic: look under the streetlight. But in those countries where the activities of the authorities are aimed at creating public goods, the governments, knowing about this feature of the intelligence services, use various management mechanisms to keep them within certain limits. Where there is a strong civil society, it controls the security forces, forcing them to do business, and not look for terrorists in the madrassa at the mosque closest to the headquarters. So the unprecedented level of pressure on doctors, veterinarians and confectioners in Russia is explained not by the fact that the employees of our Federal Drug Control Service are somehow particularly inclined to sell their souls to the devil, but by the fact that it is easier for them to report - and no one bothers them. Reporting is the main evil, which along the chain gives rise to all other evils.

At the end of last year, the Rospravosudie project analyzed publicly available verdicts under Article 228 of the Criminal Code, and this is what emerged. Almost 40% of all convictions are related to marijuana and hashish (almost 30% are related to heroin). At the same time, Article 228 has a first part that has no right to exist at all: “illegal acquisition and storage without the purpose of sale,” and 48% of all drug convictions are made under it. In other words, a person coming to us from Europe feels like we feel in Saudi Arabia, where drinking alcohol is punishable by five lashes.

But that's not all. Possession “without the purpose of sale” turns into storage “for the purpose of sale” very simply: for example, if you have marijuana in two bags, and not in one. The quantities of drugs that are considered “small,” “large,” and “extra large” in size have also been established. And if the difference between “large” and “extra large” is quite large and for marijuana the line passes at 500 g, then simply “large” starts with only 0.1 g (less than a single consumer dose).

Specific numbers are changing and may now be different, but the logic of building these gradations remains the same: they punish mainly for consumption, they imprison mainly young (under 26 years old) drug addicts, and essentially equate marijuana, heroin and, say, methamphetamine, which is simple criminal.

I am afraid that any radical changes in the situation can occur only after the demise of the current regime, which will take place in one way or another.

Pavlovsky. I am participating in a harm reduction program. We work on the street with people whom, in the context of today’s conversation, I would find it difficult to call drug addicts, since they buy the substances they need in pharmacies: we disseminate information, distribute syringes, and try to help them get the necessary medical services. But now in official government documents there are clauses about opposition to harm reduction programs, that is, to us.

But there are points about “increasing social pressure” on drug users, as if if you explain to him how bad and harmful it is, he will immediately turn to goodness and light. You might think that we already have little “social pressure”. Nowadays, few people would condemn a parent who beats a child after learning that he uses drugs, deprives him of his property and limits his freedom. Violence is the main tool of a loving parent, but it leads to the opposite result, forcing a teenager to hide drug use, pushing him out of his family and depriving him of his last support. In addition, such a person will most likely be expelled from school or college or fired from work, and problems with law enforcement agencies will automatically arise for him. In general, “social” pressure quickly pushes a person who has taken one step down the drug ladder to the very bottom: to prison sentences, homelessness, and concomitant diseases such as HIV and hepatitis. If such people want to turn to goodness and light, they have nowhere to go: there are only two hospitals in Moscow, and to get there you need a registration and a medical certificate.

When I listen to government experts, I often don't understand what they are talking about because they are describing the reality of their hospitals, not the reality of the street. The design of our current drug policy institutions is such that even objective research into the situation on the drug scene and data collection have become impossible (because drug users are afraid of official authorities and do not turn to them for help). We could become a platform, a bridge between the street and the state, but this is not happening.

Lukashevsky. Russia is a state-centric country, but still, in our society, sometimes there are processes that do not coincide in direction with state policy. Does this happen in relation to the problem being discussed, or does society “sing” in unison with the state?

Lvovsky. It seems to me that society is quite in solidarity with the state in a policy aimed at exclusion, and (although not without the help of TV and the media) does not want to tolerate the “Other” next to it, be it a drug addict or a homosexual. There are individual pockets of resistance, but this process is obvious and its vector is completely understandable. I don’t want to say that there is something wrong with our people: this is just the historical moment.

Xenophon. Almost every day I come across a manically repeating situation: you read LJ, FB or Twitter of some nice person, and suddenly there, like a bolt from the blue, is a declaration of love for Roizman. So repression is not primarily in the state, but in our heads.

Pavlovsky. We started our project 4 years ago, and have come a long way from total rejection of the appearance of people who support us, including in the space of social networks. There is some movement.

Vlasov. Just 120 years ago there were cholera riots in our country, and doctors were raised with pitchforks. Just 60 years ago there was the “Doctors’ Plot”, and we know how “grateful patients” reacted to it. But in this sense, the masses of the people in Russia are no worse than in other places, where stories of blatant aggressive savagery have occurred quite recently, and even continue to this day. Therefore, there is no need to hope for public opposition to the state. Today we have not yet touched upon the topic of expanding repression, but it is happening, take, for example, the introduction of drug testing for schoolchildren, which is most likely to take place. I’m afraid that all other interactions between society and the state will proceed approximately in this direction.

Question from the audience. What is the number of clients of the Rylkov Foundation’s harm reduction programs?

Pavlovsky. We are six volunteers. In a year we reach a maximum of 1000 people.

Question from the audience: What is the number of sentences for drug offenses?

Lvovsky and Ksenofontov. About 300 thousand, including about 46 thousand people serving sentences under these articles.

Question from the audience. What happens if drugs are decriminalized/legalized?

Lvovsky. If we talk about those drugs that we are forbidden to call soft, then as a result of their decriminalization, several tens of thousands of people will not go to prison, will not receive a stain on their biography in the form of a criminal record, and criminal communities will lose a huge part of their profits. The price will go down, so the number of crimes committed to get money for drugs will also go down.

Xenophon . Most likely, the decriminalization of hard drugs will have the same effect.

Lvovsky. The geography of drug distribution (marijuana is used mainly where hemp grows, heroin in Siberia, and krokodil in very poor regions) refutes the popular opinion that marijuana users sooner or later inevitably turn to hard drugs.

Question from the audience. Please comment on the initiative of the Ministry of Health with the recent creation of a working group on pain management, which included, among other things, representatives of hospices.

Vlasov. I think that employees of the Ministry of Health and even the Presidential Administration still do not eat children for breakfast. Even for them it is obvious that something needs to be done. But the pace of progress is so insignificant compared to the scale of the problem that one cannot hope for a quick solution to the catastrophe with access to pain relief. It would seem that everyone who knows about what is happening should think: “Now I’m 40, in 20-30 years I may have cancer and need pain relief”... But no. By the way, it is not much easier to inject a drug to a patient in need in the Presidential Administration Clinic than in a regular hospital.

Question from the audience. What advice can you give to those whose family members or children use drugs?

Pavlovsky. Firstly, continue to treat them as family, friends, children, no matter how difficult it may be. Secondly, know the rules for providing first aid in case of an overdose (most deaths of opiate users are deaths from overdose), especially taking into account the fact that “authorities” often arrive along with the ambulance in such situations. Thirdly, distinguish between drug use and drug addiction. If a person has already started using substances, but has not yet become addicted, there is a lot that can be done to help him, and not so much medically as humanly. Opiates almost never begin to be used for recreational purposes, and if a person begins to do this, it means that, most likely, he is faced with life problems that he cannot solve, pain or depression, violence.

Question from the audience. How to involve civil society in harm reduction programs?

Pavlovsky. Tell. Many would like to help, but are afraid of what they might encounter on the street. There is no need to be afraid: I have been working on the street since 2001, and during all this time I have never encountered violence, theft, etc. against volunteers from clients, and only once - from a threat from law enforcement agencies.

Lvovsky. When we talk about drug addiction, drugs, and the fight against drugs, we are not discussing reality, but cultural constructs. To a large extent, even tonight we remained within this construct. And in order to change something, you need to get out of its framework.

Xenophon. Speaking about drugs, we should not forget that there are many addictive substances, and not all of them are prohibited.

Pavlovsky. The drug problem is often seen as total and, as a result, unsolvable. Indeed, nowhere and no one has been able to completely eliminate drug use. But this is absolutely no reason to abandon the harm reduction strategy; fortunately, a lot of constructive experience has been accumulated in the world.

Vlasov. The balance of evil and kindness in society is terribly unfavorable and shifted towards the forces of evil. All the "wicked" problems, including the problem of substance addiction, are intertwined, and there is no magic silver bullet that could fix everything overnight. I wish it could happen quickly... I was still in school when President Kennedy brought in the National Guard so a black guy could go to college, and today America is led by a black president. Humanity shows examples of rapid development, although I am not very optimistic about rapid development in this area and in our country.

Lukashevsky. If you do not see a person in a drug addict, in the extreme you may not see him in a cancer patient, and in this sense, the technical, bureaucratic connection of the problems discussed today is not accidental. And one more thing. Trying to find simple answers to complex questions usually only makes things worse. And our society has yet to learn that good answers require taking into account a huge number of factors and a huge number of different little people.

The full video recording of the discussion can be viewed here: http://www.ustream.tv/recorded/29056382 , http://www.ustream.tv/recorded/29057428 .