Following the Russian invasion of Ukraine, disruption to the supply of medications for opioid addiction put people at risk of withdrawal. Medications like buprenorphine and methadone are illegal in Russia, making them impossible to obtain in occupied areas. Population migration to different regions, Russian occupation of specific areas and disruption to supply chains all created problems that endangered the treatment of people addicted to opioids in Ukraine. The responses to tackle these issues were analysed by Dr Olga Morozova’s research team for the International Journal of Drug Policy.
Strategies included increasing the length of prescriptions, more flexibility on the ordering, storage and redistribution of stock and decreasing individual dosages to prolong supplies. Since the war started, the data shows that the number of people receiving drug treatment has increased by 17% in public clinics and has likely increased in private clinics also, showing these strategies to be effective. However, those in occupied areas probably faced sudden withdrawal and the situation remains risky as supply largely depends on one factory.
Clinics providing medications to treat opioid addiction such a buprenorphine and methadone may be either pubic or private in Ukraine. Public clinics are free and run by the government but have strict enrolment criteria, whereas private clinics are paid for by patients and have fewer requirements. Public clinics report monthly to the Ministry of Health’s Public Health Centre (PHC) on patient demographics, treatment dosages and other illnesses. After the war started on February 24th 2022, data were also collected on displacement of patients to different regions and changes to treatment such as how many days of medication were supplied and their dosages. There is no requirement for private providers to report to the PHC, so the data on these clinics are sparse, however anything reported was included in this analysis.
The PHC also commissioned a healthcare provider survey in July and August 2022. Overall, 143 providers from 108 different sites in 24 regions completed the survey to detail how the war had affected their ability to provide medications to treat opioid addiction. Alongside this, a patient survey ran in June and July 2022 which randomly selected 700 patients from public clinics across eight regions in Ukraine to answer questions about their treatment experiences and how these may have changed before and after the war.
Results
The provider survey highlighted several challenges after the start of the war, including disruption to supply of medication (26%), higher workloads (20%), emotional distress (8%) and migration of both patients and staff (8%).
The disruption to supply has been worsened by the closing of the buprenorphine and methadone manufacturing plant in Kharkiv, leaving Odesa as the only source of these medications inside Ukraine. Shipments into the country are tightly regulated; at times they have had to be hidden amongst other medications when travelling through Ukraine. This has been compounded by the necessary re-allocation of funds from the government to the war efforts, resulting in a large decrease in available money, somewhat compensated by funding from The Global Fund.
To tackle these issues, the government quickly made legal changes to make things easier. Clinics could now store up to three months’ worth of necessary medication and the process for requesting stock was decentralised, making it easier for individual regions to request and control their amount of stock.
Individual clinics tried to mange their stock supplies by decreasing people’s dosages. One fifth of patients reported that their dose had been decreased, but this varied greatly depending on region. Despite this, the number of people who reported use of non-prescribed opioids in the 30 days prior did not increase when compared to what they reported before the start of the war. However, 22% of patients did reveal in the survey that they had taken a higher than prescribed dose in the last 30 days to tackle their withdrawal symptoms and 39% said they would prefer a higher dose.
These changes helped to tackle to issue of migration among patients, as many people left the clinics they were registered at after the war started but then re-registered in other areas. This greatly increased demand in certain areas, such as Lviv which saw a 55% increase in patients between February and June 2022. To facilitate migration, patients were allowed to take a 30-day supply of medication, which had previously been restricted to 10 days only. Longer prescriptions also decreased the number of in-person visits to clinics required. It seems that participants further from the frontline generally continued 10-day supplies but those in more unstable areas reported being given increased supply.
The number of doctors decreased by 4% from 258 to 247 and nurses decreased by 2% from 326 to 319, mostly because of closed clinics in occupied areas. Overall 16 sites serving a total of 1410 patients closed. Despite losing patients who remained in occupied regions, over the first year of the war there was also a 17% increase in the number of people registered with public clinics. This amounted to an approximately 15% increase in the number of patients per doctor. While it is difficult to know what is happening to patients who have remained in occupied regions, it is likely to be similar to the situation in Crimea in 2014, when treatment was abruptly terminated placing people at risk of withdrawal and death.
Conclusions
The authors concluded that the fast and efficient government legislation was crucial in helping to mitigate for the disruption to services caused by the war. They suggested a national patient registry and better communication between public and private clinics would further help support people in Ukraine who are being treated for opioid addiction. Temporary reduction in drug dosages did not seem to increase the use of unprescribed opioids. However, the situation remains uncertain due to only one factory supplying medication at present. Support for those migrating getting housing and social assistance is crucial and “the role of civil society in responding to the crisis cannot be overstated.”
Morozova O et al. Treatment of opioid use disorder in Ukraine during the first year of the Russia–Ukraine war: Lessons learned from the crisis. International Journal of Drug Policy 117: 104062, 2023.
https://doi.org/10.1016/j.drugpo.2023.104062
Full image credit: Sergei Tkachuk keeps records while distributing clean needles, condoms, and other harm reduction elements at the Step by Step needle exchange program outside the Kyiv City Narcological Clinical Hospital for Social Therapy on Thursday, November 19, 2015 in Kiev, Ukraine. Brendan Hoffman/Global Fund Advocates Network. Image available at www.globalfundadvocatesnetwork.org/campaigns/we-need-the-global-fund-our-stories/ under Creative Commons licence CC BY-NC 4.0.