We visited St Petersburg in the autumn of 1999 as the guests of Professor Leonid Shpilenya, Director of the city's addiction services, and Dr Olga Khvognova, Director of Nurse Training, College Number Three. This was part of an exchange programme financed by the Know How Fund — Health Sector Small Partnerships Scheme (Russia). Two of the authors (P.F. & A.G.) have been involved in these exchanges for a number of years. The current project is a joint one, involving medical and nursing staff (Reference Green, Holloway and FlemingGreen et al, 2000).

During the communist era drug misuse was seen as a manifestation of the ‘degenerate’ western lifestyle and not an issue in Russia. Since the 1990s drug misuse has been acknowledged as a problem at the same time as a considerable increase in the consumption of illicit drugs has occurred. There are currently some 6000 officially registered addicts in a population of approximately 5 million in St Petersburg; the unofficial figure is put at 100 000-120 000 addicts. Until 1997 most of the heroin consumed was made illicitly from locally grown poppies and sold as a liquid called ‘black’. This is injected and contains many impurities, often leading to a toxic confusional state. ‘Black’ is now being replaced by illicit heroin, the price of which has fallen; this is often smoked and its use is spreading. Recent surveys of young people show increasing substance misuse, particularly by those who come from more affluent families. Young people from more socially deprived backgrounds are increasingly misusing solvents.

Addiction treatment services

The term narcology is used for the study of addiction to alcohol, drugs and tobacco. As a speciality, it has developed separately from psychiatry since the mid 1970s and because of its low status there have often been inadequacies in the training and quality of its practitioners. Efforts are now being made to ensure that doctors specialising in addition are first trained in psychiatry. Treatment services have been hospital and medically oriented. Traditionally, patients have expected that doctors will cure them and have not taken much personal responsibility for their health. This has had significant implications for treatment of addictions, and all manner of unproven treatments have been used (Reference Fleming, Meyroyan and KlimovaFleming et al, 1994).

The services in St Petersburg are based at the city addiction clinic. This has 600 beds and is divided into a number of departments. The fabric of the building is in reasonable repair and efforts have been made to decorate many of the patient areas. We saw one of the in-patient units, which had 60 beds, 15 of which are for drug users. Accommodation was in dormitories with up to 12 beds in each. There was an intensive treatment area, where a number of detoxification techniques were used: plasmophoresis, haemabsorption and cryopurification. These methods have been developed to cope with the very toxic states in which patients present to services. In contrast, we saw a 20-bed rehabilitation unit for alcoholics, which is run on ‘12 step’ principles using individual and group therapy. It was opened in April 1998 and is a pioneer unit in Russia. Senior staff have been trained in Poland and include nurses, psychologists and social workers. Patients were kept busy during the day with lectures, videos, reading material, individual and group work — a programme similar to many in the UK. Patients stayed for 6 weeks and were introduced to Alcoholics Anonymous groups, which provided follow-up and support after discharge.

In addition to the in-patient service there are out-patient clinics in all the 20 districts of St Petersburg. We visited a recently established service for young substance users aged 11-18, the first in Russia. It was staffed by psychiatrists, psychologists, teachers and a sports instructor. It is well advertised in the city and takes self-referrals, as well as referrals from professionals, the police and other agencies. There is a comprehensive assessment procedure that involves parents, and individualised programmes of care are planned by the multidisciplinary team. Patients attend on a daily basis. The unit had been open for only 2 months and it was too early to judge its effectiveness; however, we were impressed by the enthusiasm and competence of the staff team. The building, recently refurbished, included a gym and a traditional psychotherapist's office, with the therapist's chair at the head of the patient's couch!

Neurosurgical treatment of addiction

A controversial treatment for addiction is neurosurgery, and we visited the surgeon, Dr Medvedev (the son of a distinguished psychiatrist) at the Institute of the Brain where this has been pioneered. He explained that the technique was developed following the observation that neurosurgery helped those with phantom limb pain and obsessive—compulsive disorder (which is regarded as the basis for drug dependence). The operation is performed stereotactically using 2.5 mm probes at — 78°C to destroy tissue bilaterally, either at the cingulate gyrus or anterior limb of the internal capsule. We were shown around the ward of ten beds and met pre- and post-operative patients, who invariably reported extinguished craving and few side-effects. To help fund the programme patients are accepted from abroad, paying more than double the local charge of $2500 — which is already beyond the reach of most of the population. The first operation took place in December 1998, and 50 had been completed at the time of our visit, 10 months later. Although follow-up data were limited, Dr Medvedev claimed a 70% rate of abstinence. He recognised motivation as an important factor and was developing screening tests with psychologists. Rehabilitation was another important area that they wanted to address postoperatively to prevent relapse to drug use. It should be said that this is a controversial treatment among narcologists, several of whom were sceptical of its benefits.

Future of treatment services

It is interesting to consider the changes in substance misuse services over the past 10 years (Reference FlemingFleming, 1991). These have occurred only slowly because of bureaucracy, professional and public attitudes and financial strictures. Harm reduction, while accepted by certain key professionals, is not seen as a legitimate goal by the public and politicians, for whom abstinence is the aim. Thus methadone treatment is still prohibited by law, although there are plans to set up some pilot schemes. The only needle exchange service in Russia was part of a mobile unit in St Petersburg funded by a French charity, Médicine du Monde. This was destroyed by arson within 2 years of it being set up. By contrast there has been significant development in the use of psychosocial approaches to treatment and in the role of staff other than doctors. This is mostly owing to the lead given by Professor Shpilenya, who has also encouraged the St Petersburg administration to develop policies for prevention and multi-agency work in the field of substance misuse. This augurs well for future developments.