"As noted above, human rights organizations and UN bodies have documented human rights violations against PWUD 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].

"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.

"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.

"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.

(Stigmatization and Inhumane Treatment of Krokodil Users) "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).

(Harms Associated with Krokodil Use) "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.

(Krokodil - Reasons and Risks) "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 &

(Prevalence of Krokodile Use) "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).

(Krokodil Production) "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).

(Potential Impact on HIV Transmission in Russia if Opioid Substitution Treatment Were Available) "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."