Managing Opioid Agonist Therapy in the Post-Soviet Limbo

Abstract

According to Dante, “Limbo” is the first circle of Hell located at its edge. Unlike other residents of Hell, the Limbo population suffers no torment other than their lack of hope. We argue that a lack of hope in post-Soviet Ukraine is expressed by a lack of conditions for a better future since the past is overrepresented in the present. Therefore, every movement transforms under the past’s pressure, changing its course in order to reproduce and perpetuate ghosts of what is long gone. We argue that the current state of Ukraine can be framed as “post-Soviet limbo.” If the great stability of the Soviet regime was a result of overregulation and extensive control, or of “uncertainty avoidance,” then a post-Soviet limbo is a result of “managing uncertainty” simultaneously influenced by Soviet legacies and neoliberal promises of growth, calculability, and deregulation on the part of the State. “Soviet legacies” are dominant and represent a mix of formal overregulation explicitly presented through laws and policies and informality which, according to some authors, became even more widespread in the post-Soviet period than it used to be under the Soviet rule. We do not aim to consider the past legacies as being opposite to neoliberal features and futures, but negotiate the way the two are interrelated and mutually reinforced in the present to produce the post-Soviet limbo. Ukraine’s performance of Opioid Agonist Therapy (OAT) coverage is consistently estimated as insufficient and needing further improvement. However, we argue that that there are two modes of OAT implementation in Ukraine: state-funded (formal) and privately-funded (informal). The latter’s size does not fall into official estimates since the national reports on OAT performance never include the numbers of patients involved in informal treatment. We suggest, that the informal mode of OAT implementation appeared as a result of contrasting efforts towards intensive regulation and extensive growth. To understand how these two modes are produced in the context of post-Soviet narcology, how they differ and where their paths cross, we analyze two types of texts: legal and policy documents regulating substance use disorder (SUD) treatment, mainly OAT; and qualitative data, including interviews with OAT patients and field notes reflecting the environment of OAT programs. Finally, the presented article seeks to answer how the state’s contrasting efforts to manage the uncertainty of SUD treatment through OAT regulation and implementation reproduce the post-Soviet limbo and, thus, people with SUD as “patients of the state” who are frozen in a hopeless wait for changes.