Substitution Therapy in Iran – One Thousand and One Nights Fairy Tales?

16 December 2016

It`s been two months since I returned from my trip to Iran. All this time I have been dragging my feet about writing this blog – always something or other. However, I think it´s good that I did not try to write about Iran as soon as I got back – all that information, impressions, and emotions just would not fit into a short blog entry, I could have written a novel, at least! Now everything has settled in my head and I can try and write about the most important things.

Аnd the most important thing is that Iran has managed to build its own harm reduction system, sustainable in its own way. It is not like any other western system and not quite like the systems described in manuals and recommended by WHO and UNAIDS. There is one million and three hundred thousand of people who inject drugs in Iran and more than 400 thousand of them get opioid substitution therapy (OST). Yes, you read it right. We asked different people in different agencies and it is true – in the last years the number of OST clients has risen to 430, 000. Iran’s Drug Control Headquarters, Ministry of Health, Social Welfare Organization, and National Centre for Addiction Studies are very proud of this number. 

Add to this another 50 thousand people who get OST in prisons. Now, I am having mixed feelings about this. It is certainly great that prisoners have access to OST. But fifty thousand prisoners in need of it? Obviously, the Iranian laws on drugs are not very tolerant to people who inject drugs. 

Вut let´s not jump ahead. Substitution therapy was first introduced in Iran in 2002, at about the same time as in most countries of the EECA region. How did Iran manage to do what most of the EECA countries have failed to do – namely, to move from pilot projects to such a high level of coverage?

First of all, thanks to a transparent system of certification and licensing. Not only state-run but also private clinics and non-profit organizations can offer substitution therapy services. The requirements are the same for all. Staff members (a general practitioner and a psychologist) must receive certified training in the National Centre for Addiction Studies, and the organization itself must obtain a license from the Ministry of Health. There are no strict demands to the premises where substitution therapy is handed out. No video surveillance, no security bars, no police officers were spotted in any of the OST sites (and in our four days in Tehran we visited quite a number of them).  Distribution of methadone and buprenorphine is controlled but the OST sites do not look like military objects. 

NPOs offer OST in drop-in centers. These are the places to drop in, literally: visitors spend a lot of time there: they chat, eat meals together or learn to use computers. The only difference between an OST center run by an NGO and a state-run center or a private clinic is this: at an NGO facility, it is not allowed to give methadone and buprenorphine to clients to take home, except for the weekend.  If you are on therapy at a state or a private clinic, after a few months you can start getting your medication for a week.

The criteria for enrolment in an OST program in Iran are fairly loose: one should have HIV or hepatitis or fail drug addiction therapy or just use injectable opiates. If you meet at least one of these criteria and are older than 18, you will be getting OST. Many people who use drugs in Iran have no documents, but that is not seen as an obstacle to therapy.

Are you thinking “well, where is the catch”, too? It´s just too good to be true…
When I was told that clients should be paying for their OST, I thought – yes, that´s it! The state is funding these programs but the investments are in minimal amounts. Patient cost sharing is compulsory for enrolment.  Still under the charm of the Iranian programs, I decided to find out how come half a million Iranians could afford OST. I was thinking about Georgia – a state where OST programs are also partially paid for by the patient. However, one cannot speak about any sustainable OST in that country as monthly payments prevent many patients from getting treatment on a regular basis. What is Iran doing differently then?

First, the cost of OST – a client pays about 20 USD a month (that´s the cost of the medicine only, the state pays for the services of a doctor and psychologist). An average monthly income in Iran is about 500 USD, so it is small money for those who have a job. To compare: an average monthly income in Georgia is 364 USD and their OST patients pay about 60 USD a month to stay on therapy.

However, most of the clients in Iran have no income, many of them are homeless. The Iranian harm reduction programs give them shelter and free meals three times a day. The program staff members say it´s not such a big deal to find 20 USD a month to buy methadone or buprenorphine. Many of their clients collect garbage in the streets or do other low-paying jobs. They can afford to pay for methadone or buprenorphine. If one has no money at all, a social worker from the harm reduction program gets involved. The social worker goes to the Social Welfare Organization and gets reimbursement of the program costs for such a client from the state budget. It is a routine situation, but such clients are rare.

Decent prices for methadone and extremely low prices for buprenorphine in Iran can be explained by the fact that these drugs are manufactured locally. Iran is also a manufacturer of an opium tincture, a drug that is currently being tested as another possible medication for OST. The internal production plus a huge market volume allows for the program cost to stay low enough for the client.

Opioid substitution therapy is just one treatment option for a drug addict in Iran. Rehabilitation centres with 12-step programs are widely spread. They are not free of charge but affordable if you compare them with most of private rehabilitation programs in EECA – in Iran they cost about 160 USD a month. Many of those after successful treatment later decide to study and get a state certificate of an Addiction Consultant.  Such a job in harm reduction programs is their ticket back to society. These guys had nowhere to live when they first came to harm reduction programs as clients and, as outreach workers do not earn enough to afford their own accommodation, many drop-in centres provide permanent housing for their staff. The state is trying to solve the problem. An official of the Social Welfare Organization told us that last year they provided free accommodation to about one thousand successful rehabilitation program graduates who had abstained from taking drugs for a year. This sounds like science fiction. Or like a fairy tale from the Arabian Nights.

From October 17 to October 19, 2016 a delegation of officials from the Republic of Kazakhstan visited the Islamic Republic of Iran. The aim of the visit was to study Iranian experience in implementing harm reduction programs and policies at the national and municipal levels, state funding for harm reduction programs, and financing mechanisms for non-profit organizations engaged in providing non-medical services under such programs. The study tour was organized by EHRN under the regional program “Harm Reduction Works — Fund It!”, supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria, the UN Department on Drug and Crime in Iran and the Iranian Drug Control Headquarters. For more details please see http://www.harm-reduction.org/ru/news/officials-republic-kazakhstan-will-learn-iranian-experience-harm-reduction.

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