There are three people in the room, but the voices of only two are heard. The main subject of the dialogue is the third person, who was not “awarded” the privilege of participating in this discussion. And the conversation continues about him, in the third person. It’s probably difficult to be a “voiceless” object… While we might need to use our imagination to experience this, for people with substance dependence, this is a reality, without any “probably.”
Generally, when discussing dependence, linking it to a “flaw” in willpower echoes 19th-century views. During that period, it was believed that people with substance dependence could recover on their own, simply by mustering up willpower. Accordingly, treatment was mainly focused on “spiritual correction.”
If we follow a chronological path, substance dependence has come a long way from moral judgment to a medical diagnosis. However, knowing the historical context alone cannot clarify the etiology. So why does dependence develop? This question was asked centuries ago, which is why we certainly don’t lack hypotheses today.
There are several hypotheses about the causes of dependence: while the dopamine theory explains dependence as a disorder of the brain’s “reward system,” where substances artificially increase dopamine levels and gradually train the brain to this supra-threshold stimulation, the self-medication hypothesis places emotions at the center. It focuses on the psychological aspect of why people use substances to cope with difficult emotions and mental health problems. The biopsychosocial model attempts to unify these causes into a single picture. It explains that dependence is a complex problem in which genetic, psychological, and social factors participate equally. That is why not everyone who uses a substance becomes dependent.
Given the complexity of substance, and specifically opioid, dependence, the ways countries deal with it also differ:
In the United States,particularly in New York, Supervised Consumption Sites have been established. These are places where people who use drugs can consume psychoactive compounds safely, in a clean environment, and under medical supervision. Although a part of the public perceives these spaces as encouraging consumption, the main goal is to care for safety, specifically to reduce the risk of overdose and infections. At the same time, it becomes easier for users to access social services.
Canada uses a combined approach: opioid substitution treatment (methadone, buprenorphine) is supplemented with various support services, which are available in clinics and pharmacies, as well as in prisons. This approach ensures integrated care and public support.
European countries offer various models: from harm reduction strategies to abstinence-oriented programs. These approaches are tailored to the social and political context of each country.
Against this background, Georgia has chosen a different path: the opioid substitution treatment program is being completely transferred to the state, which means that all private centers that provided this service will be closed from August 15.
In the future, instead of direct access to private clinics, patients will have to register on a special state platform. This centralized system aims to enforce stricter control over the treatment process and create a database to make patient management more effective. However, this change may cause bureaucratic delays and limit patient choice, which was previously ensured by the existence of the private sector.
In global practice, substitution therapy is rarely managed solely by the state, with the complete exclusion of the private sector, which raises questions about the effectiveness of this approach. The plan to transfer opioid substitution treatment (methadone, buprenorphine) to state control in Georgia has caused an active public discussion. The main question is—how should this process be carried out so that the mistakes made in the past in treating dependence are not repeated?
“Treatment with opioid agonists should be accessible to everyone who needs it,” says Dr. Irma Kirtadze, a public health doctor who has been working for years in the field of drug policy and harm reduction.
According to her assessment, if monitoring increases fear among patients due to violations of confidentiality, stigma, or bureaucratic barriers, trust will be weakened and the risk of treatment discontinuation will increase: “If human rights are violated at the foundation of service provision, it does not matter whether the state or a private entity provides the treatment.”
Beyond the logistics of the reform, for Irma Kirtadze, the main thing is compliance with international standards: the joint document of the United Nations Office on Drugs and Crime (UNODC) and the World Health Organization (WHO), International Standards for the Treatment of Drug Use Disorders (2020), states that the first principle of treatment is that it must be accessible, attractive, and adapted to the individual’s needs. This implies easily accessible services and a flexible, patient-centered approach. Treatment must be evidence-based and ethical, protecting the patient’s consent and rights.
Kirtadze fears that if these principles are deviated from, for example, by relocating centers to the suburbs, geographic accessibility will worsen or the sense of confidentiality will be questioned, many patients will refrain from joining the state program and will be left without treatment: in such a case, the probability of relapse and returning to the use of street drugs is high, which in itself increases the risks of overdose, HIV/AIDS, hepatitis B/C, and other blood-borne infections, as well as crime, mortality, and chronic morbidity.
Medscriptum spoke with Maka Gogia (Georgian Harm Reduction Network) to assess the potential benefits and risks of the reform.
Salome Chkheidze: Regarding the reform of opioid substitution treatment, perhaps the most clear aspect is the registration process itself. However, a fundamental question arises: in the attempt to better control the program, have the real challenges that patients face daily been lost?
Maka Gogia: That’s a very good question. Both before the reform and now, challenges such as the need to go to the program daily to receive a dose are still relevant. For stable patients who have been in the program for years with good compliance, there is no possibility of taking several days’ worth of doses home, which would, to some extent, encourage them to stay in the program for a long time. Imagine that for years, patients have no opportunity to go on a work trip or take a vacation with their family outside the country.
In addition, patients often talked about overcrowded programs, where a patient does not have contact with a doctor for months because we do not have enough narcologists. For context, one center serves up to 1,000 patients. Patients from private programs will be added to the existing programs. This will further increase the burden on these centers. It will be difficult for doctors and other medical personnel to work.
Salome Chkheidze: A statement published by the Ministry of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs two days ago mentioned that registration is actively underway and hundreds of beneficiaries have already been registered. How relevant is the involvement of hundreds of people compared to the number that should be recorded, if we consider the real number of beneficiaries?
Maka Gogia: There is a danger that a significant number of people from private programs will not transfer to the state program. There are several reasons for this. The first is the fear of their personal information being disclosed. They believe that private programs were more careful with their information, and because of this, they were able to work in various jobs without problems, including in public institutions. In addition, after entering the state program, they are afraid of losing their driver’s licenses, which they absolutely need to get to the program, especially given that some of the programs have been moved outside the city, and soon all programs are planned to be moved out. A certain geographical barrier has been created for the beneficiaries of the program, which will definitely be reflected in their participation in the program. This will also affect their families, who will need more effort and money to drive the patients to the programs every day (as you know, many of them have various chronic diseases, which makes it quite difficult for them to go to the program daily).
