Page 28 - GHES-2-4

Global Health Economics and
Sustainability
OAT in Central Asia: Kyrgyz Republic

Table 2. Recommendations for reducing barriers to opioid agonist therapies and supporting sustainable scale‑up of treatment
Observed barrier Recommendation
Requirement for daily in-person treatment 1. Add sublingual and/or long-acting injectable buprenorphine to the national formulary.
2. Expand take-home dosing options, as during the COVID-19 pandemic, and allow
longer periods of take-home self-administration.
Subtherapeutic methadone doses among many program Encourage providers to prescribe higher doses, as indicated in the new 2022 clinical
participants (Ivasiy et al., 2022) protocol, particularly for patients receiving treatment for HIV or tuberculosis.
Dilution of liquid methadone causes logistical shipping 1. Add sublingual buprenorphine to the national formulary.
difficulties 2. Allow transport of more concentrated methadone formulations.
3. Allow tablets rather than liquid formulations.
Lack of OAT site accessibility and possible migration to 1. Allow any licensed prescriber to prescribe OAT, perhaps with limited training.
areas without methadone sites 2. Expand the types of clinics allowed to dispense OAT (e.g., primary care clinics).
3. Create clear guidelines for transitioning into and out of the program to account for
internal and external migration (e.g., if people go to work in the Russian Federation or
another place without methadone).
4. Allow longer take-home dosing options for people who live remotely from OAT sites.
Patient fears of consequences of registration Remove the registry entirely or establish clear guidelines for removing stable methadone
patients from the narcological registry.
Police harassment of program participants 1. Incentivize police to refer people who inject drugs to needle/syringe exchange
programs and/or OAT.
2. Foster partnerships between methadone programs and local police departments.
3. Train police on harm reduction and the benefits of OAT for public safety.
Abbreviation: OAT: Opioid agonist therapies.
of methadone, as described above, may also contribute government – —a process that can bar them from future
to the declining number of participants. Despite efforts employment opportunities or even from obtaining a
to reform law enforcement interactions with people driver’s license (Eurasian Harm Reduction Association,
enrolled in methadone programs (on Measures to Reform 2019; Regulations on the Rules and Procedure for
the System of Law Enforcement Agencies of the Kyrgyz Identifying, Registering and Recording in Public Health
Republic, 2016), police harassment of program participants Institutions of the Kyrgyz Republic Persons Who Allow
remains common (Katkalova, 2021). Prescribed doses Non-Medical Consumption of Psychoactive Substances,
remain lower than those recommended by international 2001). Similar policies in other EECA countries have
guidelines (Ivasiy et al., 2022), and higher dosing is continued to hinder access to treatment (Bojko et al., 2013;
associated with better quality of care provision and 2015; Makarenko et al., 2016; Mazhnaya et al., 2016). By
increased willingness among patients to start and remain law, registered individuals are barred from working in
on methadone treatments (Farnum et al., 2021). Within state or municipal services, educational institutions, and
prisons, individuals who wish to join the methadone taxi companies, among others (Eurasian Harm Reduction
program face significant social barriers (Liberman et al., Association, 2019; Labor Codex of the Kyrgyz Republic,
2021), including a social hierarchy that opposes methadone 2004). While the program aims to protect the community
use and restricts access to work, food, and recreation by preventing people who use psychoactive substances
incarcerated people (Azbel et al., 2022; Azbel and Altice, from operating heavy machinery or performing similar
2022; Meyer et al., 2020; Ponticiello et al., n.d.). tasks, in practice, it creates a major barrier for individuals
with substance use disorders to seek treatment. Before
The Kyrgyz Republic’s methadone program in the seeking treatment, a person may not be on the registry, but
Kyrgyz Republic has also encountered several political once a public clinic is aware of the person’s substance use
challenges. Most notably, a 2011 documentary titled disorder, registration is required, leading to the loss of their
“The Trap” demonized the program, leading to calls for driver’s license and potential barriers to employment. In
its closure (Trilling, 2012). Despite this, the program addition, once registered, it is difficult to be removed from
continued to expand until 2017, when the number of the registry; although the laws and protocols dictating the
participants began to decline. registration process are detailed, the deregistration process
Individuals seeking treatment for substance use is unclear.
disorders, including methadone for OUD, must first be The consequences of mandatory government
diagnosed with OUD and then officially register with the registration have been discussed and analyzed extensively,

Volume 2 Issue 4 (2024) 7 https://doi.org/10.36922/ghes.2536