For nearly three decades, Ukraine has experienced the worst HIV epidemic in Europe. People living with HIV in Ukraine make up approximately 1% of the Ukrainian population and represented nearly 10% of all new HIV cases in Europe in 2022. As I discuss in my book, Narkomania: Drugs, HIV, and Citizenship in Ukraine, significant international involvement in Ukraine’s healthcare and public health sectors has been predicated on the need to effectively respond to and control Ukraine’s HIV epidemic, with many of those efforts targeting people who use drugs, among whom HIV infection is most concentrated. Key among those international efforts has been the work of the Global Fund, which invested significant financial and institutional resources in HIV testing and treatment as well as evidence-based services for people who use drugs, including the expansion of harm reduction and syringe services programs as well as the expansion of medication treatment for opioid use disorder (MOUD).
MOUD, which utilizes one of two evidence-based opioid agonist medications, methadone and buprenorphine, was first introduced in Ukraine in 2004. Since then, access to evidence-based, life-saving MOUD has expanded into every region of the country, with more than 17,000 people receiving MOUD through state healthcare institutions by January 2022. At the same time, people living with substance use disorders have faced extreme stigma and discrimination not only for socially taboo behaviors but for the ways in which widely held beliefs about addiction, or narkomania, align with other, powerful forms of social distinction that dehumanize through the denial of one’s internal moral compass. IDPs, separatists, Russian collaborators, and many others have been—and often still are—dehumanized and dismissed as cattle, zombies, slaves, animal, and narkomany.
War clarifies as much as it obscures. Massive social, cultural, and political transformations have been taking place in Ukraine since the beginning of Russia’s full-scale war. Even though much remains to be seen about the long-term consequences of this war on Ukrainian society, echoes of old narratives and newly-constructed social tropes are already emerging from this period of rapid change. This essay provides an overview of recent developments in Ukrainian drug policy and discourse—especially those related to medical cannabis—offering guidance for a new agenda for the ethnographic study of personhood, citizenship, and technologies of the self through the framework of addiction imaginaries in a Ukraine transformed by full scale invasion.
Addiction Imaginaries and Drug User Health Before the War
Substance use and addiction, broadly speaking, are rich, symbolic, and ideological domains of social inquiry. In Ukraine, as elsewhere, popular imaginations of drug use and addiction have functioned as powerful tools for making claims about personhood, social distinction, moral rightness, and state sovereignty. Through the early 2010s, for example, Ministry of Health officials and harm reduction advocacy organizations were in regular conflict over whether people who used drugs were fully fledged Ukrainian citizens entitled to health care or sources of risk from whom “worthy” citizens of Ukraine were entitled to protection. Leaders of the Russian Federation used accusations of substance use on the Maidan to discredit Ukraine’s revolution of dignity, asserting that protestors were simply drug-addled hooligans experiencing drug-induced psychotic breaks. Ukrainian media and members of the Ukrainian army regularly represented fighters in the breakaway regions of Luhansk and Donetsk as drug users or drug suppliers as a method for dehumanizing those fighters and dismissing the complex reasons why they might be fighting within the Russian-led separatist movement. And in Crimea, where nearly 800 people were receiving gold-standard medication treatment for opioid use disorder (MOUD) at the beginning of 2014, Russia ushered in its annexation of the region by unilaterally shuttering all MOUD clinics in service of making Crimea a truly “Russian” place—Russia being one of the few countries where evidence based MOUD is prohibited on ideological grounds—resulting in the deaths of no fewer than 100 and as many as 400 of those patients in the subsequent months.
Today, as Russia wages full-scale war on Ukraine, its media continues to leverage accusations of substance use against Ukrainian military forces through reports of “opioid and ephedrine substances at positions abandoned by Ukrainian military personnel.” The use of substances—particularly stimulants and other alertness or performance enhancing substances—is not uncommon among service persons in active war zones. However, Russian reporting on alleged drug use among Ukrainian military personnel fails to acknowledge this, focusing instead on claims that giving drugs to soldiers was a regular practice in Nazi Germany and in the U.S. military during the Korean and Vietnam wars. One report from Russia’s state owned TASS News Agency read, “Such drugs cause addiction and result in such side effects as excessive aggressiveness, which explains extreme cruelty towards the civilian population by some Ukrainian soldiers, as well as the bombardments of cities in Donbass.”
Ostensibly, this symbolic work is undertaken to discredit and dehumanize the military personnel who are actively resisting the Russian invasion. But this strategy relies on a circular, load-bearing logic: that “drugs” are bad, therefore/because people who use them are bad. Yet the line separating “drug” from “medicine” or “good” from “bad” is a slippery one that varies across time and place. Russia’s war in Ukraine seems to have spurred a number of shifts in these symbolic-regulatory domains, and there is no better example of this than Ukraine’s rapidly evolving cannabis policies.
Emerging Landscapes of Distinction: Medical Cannabis
Ukraine’s parliament recently passed a legal framework for the production and dispensing of medical cannabis. This was not the first effort to legalize medical cannabis in Ukraine. In 2019, a draft law on the legalization of medical cannabis received strong support from the Verkhovna Rada Committee on Human Rights, National Minorities, and International Relations; then minister of health Ulana Suprun began voicing support for the bill. A survey at Bohomolets National Medical University found that about 80% of pharmacy students supported the legalization of cannabis for medical use. The acceptability of medical cannabis has spread widely, and today polls indicate that up to 70% of Ukrainians are in favor of legalized cannabis.
The current medical cannabis law, which garnered so much media attention, was signed by President Zelensky on February 13, 2024, and went into effect six months later on August 13, 2024. Importantly, the current law only lays out the legal framework for the cultivation and regulation of medical cannabis. It does not specify what conditions may be eligible for cannabis treatment or which healthcare providers with what scope or scopes of practice will be empowered to prescribe this treatment. Rather, the Ministry of Health holds the authority for making these determinations and must subsequently produce the list of diseases for which cannabis can be prescribed. I’m not aware of any public communication about the development or eventual content of that list from the Ministry of Health, but we can reasonably guess what will be included. In 2019, Minister Suprun touted cannabis as appropriate for diseases such as cancer, chronic pain, IBS, Crohn’s disease, multiple sclerosis, epilepsy, and Alzheimer’s. Mariia Mezentseva, a representative who supported the current medical cannabis law in the Verkhovna Rada, told reporters that medical cannabis was needed by many Ukrainians, including cancer patients, those experiencing post-traumatic stress disorder as a result of Russia’s military aggression, and soldiers who had been wounded defending their country.
Indeed, the hypothetical recipients of legal medical cannabis are consistently framed in public discourse as worthy, blameless persons with real needs that should be met with compassion, thus simultaneously framing medical cannabis as an inherently compassionate response. The needs of injured or affected members of Ukraine’s armed forces were perhaps most frequently centered in conversations about the utility and appropriateness of medical cannabis not only in the media, where emphasis is placed on PTSD, pain, and phantom pain among amputees, but among the general population as well. Many Ukrainians with whom I discussed this law in the summer of 2023 voiced their support for the legislation because they viewed it as a necessary support for service members. But other segments of the public were invoked as well and profiled in sympathetic articles in the Ukrainian media that appeared crafted to humanize medical cannabis patients and elicit emotional responses to their plight from readers. For example, Hromadske, a not-for-profit journalistic organization in Ukraine, published lengthy profiles of persons who may benefit from medical cannabis: Tatyana, a breast cancer survivor, who used cannabis to control pain and prevent the need for drugs like sedatives or antidepressants; Svetlana, with breast cancer, who used cannabis oil during chemotherapy to help her sleep; Evgeny, diagnosed with neurosis, who used illicit stimulants like cocaine and methamphetamine, but now uses cannabis, which suffices as a sedative to help control his symptoms.
Public narratives often tie the worthiness of these hypothetical medical cannabis patients to the reification of the genuine need that these hypothetical patients embody. In a public speech in support of the legislation, Ukrainian president Volodymyr Zelensky remarked,
All the world’s best practices, all the most effective policies, all the solutions, no matter how difficult or unusual they may seem to us, must be applied in Ukraine so that Ukrainians, all our citizens do not have to endure the pain, stress, and trauma of war. In particular, we must finally fairly legalize cannabis-based medicines for all those who need them, with appropriate scientific research and controlled Ukrainian production.
Similarly, the Kyiv Independent cited parliamentarian Olha Stefanishyna, who stated that Ukraine could have up to 4 million veterans after the war and, when cancer patients are included, there could be as many as 6 million people who need cannabis treatment. In particular, Stefanishyna emphasized the view that ongoing criminalization of cannabis de facto transforms honorable service persons who are engaging in medically acceptable treatment by using cannabis into criminals. “They take a risk [buying drugs from dealers],” she told the reporter, “because they want to live a normal life.”
This phrase, “to live a normal life,” stood out to me because it was the same language used by numerous MOUD patients who participated in my research when discussing their motivations for engaging in this form of treatment. I am under no illusions that soldiers defending Ukraine and civilians seeking treatment in public clinics will be received in the same way when they make this identical claim, but the salience of this framework and the richness that lies beneath the surface of a phrase like “to live a normal life,” as illustrated by its repeated contemporary use, evidences a domain of social values, social inclusion, and social distinction that merits ongoing investigation.
These recent and ongoing changes in Ukraine’s drug policies are indicative of shifting social perceptions of substance use as well as something that medical anthropologist Caroline Parker has called “pharmaceutical splitting” – the construction of socially, legally, institutionally, and even racially reified distinctions between different types of drugs and different types of people who use them. Parker’s foundational example of pharmaceutical splitting involves the multivalent distinction, shot through with already salient distinctions of class and race, between “legitimate pain patients” and “opioid abusers” in U.S. drug policy and healthcare practice. Will we see—or are we already seeing—distinctions in the perceived validity or worthiness of certain substances, the people who use them, and the contexts in which they are used? How will these distinctions shape whether individual Ukrainians receive social support or stigma and discrimination, are viewed as worthy and entitled or unworthy and appropriate to cast away? Even though it has nothing to do with opioids, per se, this new legislation and its social consequences might have the most significant impacts on MOUD patients, people who use other drugs, and the addiction imaginary writ large in contemporary Ukrainian society.
Drug Policy Research is Key to a More Complete Anthropology of Ukraine
This essay has detailed a symbolically and statutorily significant change in drug policy and drug-related discourse in Ukraine since the beginning of Russia’s full-scale invasion. Such change has resulted in new contradictions, juxtapositions, and forms of social distinction that will likely continue to hold sway in Ukrainian society for a long time to come. It can be said that many longstanding social narratives about drugs and the people who use them have been reinforced by the events surrounding Russian aggression. Yet, others have shifted or diminished in the face of more urgent national priorities, opening new possibilities for the construction, affirmation, or denial of personhood and/or social inclusion through drug-related discourse. All these developments necessitate a significant retheorizing of Ukrainian addiction imaginaries and the widespread processes of social inclusion and exclusion that they support. Future research should take up these issues, exploring not only the political machinations of those who seek to exploit shifting narratives for their own purposes, but also the impact of these changing narratives on individual members of Ukrainian society who are touched by these issues in real and direct ways.
Jennifer J. Carroll, PhD, MPH, is an Associate Professor of Anthropology at North Carolina State University.