Subu Must Die

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WORLD MAY 7, 2013

Subu Must Die How a nation of junkies went cold turkey

Needle drugs seldom make a city look pretty, but some cities are more disfigured by them than others. In 2006, when I first visited Tbilisi, Georgia, it had all the wrecked majesty of an ex-beauty queen with six years of track-marks down her arms. It was a great European capital in decay: crumbling bridges, refugees from war, and—most of all—cast-off syringes everywhere. Alleys, parks, and tunnels under the Soviet-style boulevards all had this spiky detritus, which badly spoiled Tbilisi’s old-world romance and instead put it into a permanent state of biohazard.

So when I returned this year, I packed thick-soled shoes. It turned out that, but for the frigid temperatures (and my own self-respect), I could have worn Tevas. The syringes, which once pumped opiates into the veins of as many as 250,000 addicts, are absent. The subway now feels safe, clean, and orderly, with no trash more revolting than a Snickers wrapper. The tunnels under Rustaveli Avenue still smell pissy, but so do most big cities’ tunnels. If the addicts are still there, they have been persuaded to shoot up with greater discretion. And if they are now gone, the Georgians have accomplished something remarkable, which is the rapid diminution of smackheads.

Charting Georgian drug abuse through time, you’d see a low baseline, starting when Georgia won its independence from the Soviet Union in 1991; a lack of free trade meant few drugs. Then, during the chaos of the ’90s, the line would jump a few times, with little epidemics of heroin—called shavi, or “black,” for its tarry appearance—club drugs, and marijuana. Georgia was spared widespread alcoholism, perhaps because it alone among ex-Soviet states is a wine-sipping land, instead of a vodka-slamming one.

But starting after 2000, you’d see the line jump dramatically, as if stuck in the ass with a syringe. What drove it up was an opiate called buprenorphine—brand name Subutex, street name “subu”—that effectively did not exist in the country before 2000. At its peak, one in 20 Georgians was on hard drugs, with Subutex driving the epidemic. “It was like a millennium gift for Georgians who wanted to use drugs,” says George Tsereteli, a physician who is a member of Georgian parliament.

And now it’s gone: from zero users to hundreds of thousands and back to zero again, in a decade or less. The journey has been torturous, a case study in grotesque consequences and appalling trade-offs—some former Subutex devotees have taken to injecting pills dissolved in gasoline instead—and it shows that, whatever you think the solution to drug abuse is, you’re probably mistaken.

Abbie Hoffman once said that the only dope worth shooting was Richard Nixon. But Hoffman was a free-love hippie, and sex is an effective anti-drug. The first addict I met in Tbilisi—a man I’ll call Pavel—had no such consolations. He lived a joyless life in an existential depression, and he started shooting Subutex because it has many of the relaxing, time-killing properties of opium or heroin, but with none of the likelihood of it stopping his heart.

At 38, he has the sallow skin of a wax statue and the soulless eyes of Vladimir Putin. He runs a market stall in Tbilisi, and he wears the modest clothes of a workingman. But he trained as a lawyer in university and—like most university graduates in this country—failed to find work befitting his education. Instead, he found opiates and has indulged almost nonstop ever since. We drank tea in his doctor’s office, and the chill in the room wicked the heat from our teacups within minutes, giving me a taste of Pavel’s own wintry life. In the early days, when he had the money, he took heroin and opium. Now he’s on doctor-prescribed methadone, as he tries to go sober.

But the best period of his life was his eight-year romance with Subutex. “Subutex was my only happiness during my period of addiction,” he says. “If I could, I would inject seven or eight times a day. But once or twice a day was the minimum.” He says the highs never matched the highs from heroin. They lasted longer, though, and he could at least be confident that he was shooting a pure product.

It’s no surprise that Subutex got him off heroin. In the ’90s, after a decade of clinical use as a painkiller, Subutex was introduced to wean addicts off the drug, much in the same way that methadone has been used since the 1960s. But Subutex is a major improvement in several ways. First is the experience of patients: Methadone can put users in a sick stupor, but Subutex is so mellow and unobtrusive that they can drive cabs or wait tables while on it.

The second big improvement is its safer and more effective schedule of delivery for patients. Methadone’s reputation has taken a beating for some years, as doctors have observed how often addicts relapse or just keep taking methadone. They become permanent patrons of methadone clinics, showing up daily like pigeons at a park frequented by old ladies with breadcrusts. The owners of the clinics make a bundle. “Those methadone clinics are cash cows,” Mark Kleiman, a drug-policy expert at UCLA, says, adding that “a lot of state senators from ghetto areas” end up with a financial interest in them, giving them an incentive to keep better drugs off the market. The clinics require armed guards, because addicts will do anything for an extra dose of the blue, Windex-like fluid.

I do mean anything. Consider that, in 2010, an inmate in British Columbia died after drinking the puke of another methadone patient. The market for methadone vomit in prison is lively, and the preferred recipe for this cocktail is one part puke (strained, please, bartender) to one part Tang. And this leads to methadone’s biggest drawback: If you take too much of it, it will kill you. In the United States, about 5,000 methadone users die every year, making it the single-biggest killer among prescription painkillers.

There’s no market for Subutex vomit. Subutex comes in a white tablet, which the patient gets from a pharmacy and dissolves under his tongue over three to five minutes. That means Subutex users aren’t forced to visit clinics daily, dramatically increasing the efficiency of delivering doses to compliant patients. It also means, of course, that Subutex patients have a much, much easier time diverting their supply to illegal markets.

A major reason it’s safe to dispense Subutex at pharmacies is that Subutex almost certainly won’t kill you. Methadone builds up in the body and slows down breathing to the point of death. Add alcohol or heroin, and the odds of death go way up. But even in combination with other drugs—and Subutex is often taken with other sedatives or benzos—Subutex will reliably yield a long, chilled-out, survivable high.


Illustration by Tyler Wintermute

This level of safety holds even if addicts take Subutex intravenously, as Pavel and almost all other street addicts did. “I put the tablet into an empty syringe, pressed the plunger to crush the tablet into a powder, then added water,” he says. The milky mixture is then ready to inject.

The high lasts between twelve and 24 hours, which is several times the length of a ride on heroin. “If someone injects heroin in the morning, he is in withdrawal in the evening,” Pavel’s doctor, Zura Sikharulidze, says. “With Subutex, you inject it once a day and feel great till the next day.”

Pavel didn’t know how subutex got to Georgia—all he knew was that it did get there, and he could send off a dim-witted courier (called a pekhi, or “leg”) to pick a tablet up from a dealer and bring it home. The pekhi never took more than an hour to return with a dose.

But my Georgian-language phrasebook, printed by the Paris publisher Harmattan, gave me an early hint about how Subutex arrived. “The fellow-feeling of the Georgians for France is ancestral,” it said. “The French discover Georgia, and become fervent and faithful friends.” Both countries produce wine in industrial quantities, the book said, and they share with Lebanon alone the ability to ski in the mountains and tan at the beach all in the same day.

Those close cultural ties turned out to be disastrous. French doctors started using drug substitution programs in the mid-’90s, and they mostly prescribed Subutex. The only problem, however, was that a significant minority of the Subutex patients in France simply sold their pills.

Tbilisi has, not surprisingly, some highly experienced addiction doctors, and one, Dato Otiashvili, is writing a doctoral thesis on Subutex. “One tablet prescribed in Paris cost about one euro at the pharmacy,” he says. “It then sold on the street there for about ten euro”—a modest markup for illegal drugs. The real profit, however, came from export. The tablets, transported to Tbilisi on a wave of fellow-feeling, sold in Tbilisi for no less than 100 euro and sometimes as much as 300 euro at the peak of demand.

Georgian addicts aren’t rich, so they typically split the tablet four to eight ways, for a total of 100,000 doses on the diverted prescriptions of French Subutex alone. Germany and Italy began prescribing Subutex, too, and their users sold their doses to make up the balance of the supply. Other countries experienced Subutex epidemics (in Finland there was a documentary about the drug called Reindeerspotting), but none rivaled the scope of Georgia’s.

What made Subutex distinct from the Georgian heroin epidemics of the ’90s was that gangsters ruled the heroin trade, and no one could expect to sell on their turf without major repercussions. That wasn’t true of Subutex. “At the beginning, it was delivered by ordinary people who were not from drug-trafficking environments,” Otiashvili says. “They just learned about the opportunity to buy something in Paris, and sell it here, and get a nice amount of money.” A blister-pack of tablets in one’s coat pocket could easily pay for the plane ticket to Paris.

So Subutex started off as a “safe” drug—safe to traffic, because you wouldn’t get waxed by the Georgian Keyser Söze; safe to use, because it wouldn’t stop your heart; and indeed safe from legal repercussions, because police weren’t looking for it, and even if they were, they couldn’t tell if you’d been using it. “External signs of intoxication are much less visible than in the case of heroin,” Otiashvili says. Heroin gives the standard Trainspotting effects—zoning out, eyes like saucers, total incapacitation. But Subutex gives such a mellow ride that cops had no idea who was on it and who wasn’t. Even if they suspected use, they had no urine tests for it until 2002.

In time, Subutex smugglers became more sophisticated. Organized crime took its cut and piggybacked their drug smuggling on the already burgeoning used-car market. Georgia is filled with used cars—some bought, many stolen—from Western and Central Europe. Before crossing the border with them, smugglers packed their side panels with Subutex. The value of the car was tiny compared with the value of its contents.

Late in the epidemic, Georgian officials brought up the matter to France (Are you aware that your policies are causing our little country to be flooded with opiates?), but in the end, Georgia had no leverage on the international supply-side. “We are a small country aiming to join all the European Union,” Otiashvili says. “We are not going to enter a complaint with one of the strongest countries in the EU.”

By 2005, Georgians came to view drug addiction as their country’s second-biggest problem, after unemployment (then hovering at 13.5 percent) and before the still-unresolved Abkhazian civil war, which left the northwest wedge of the country in control of Russian-backed separatists. Still, Otiashvili says, “Subutex was Enemy Number One.” Needles sprouted from the soil of Tbilisi’s public parks like thorns and nettles, and Georgia wanted a leader willing to enforce radical law-and-order solutions and make the Subutex users suffer.

In other words, Georgia wanted someone willing to imprison drug abusers and punish them as harshly as we do in America. In 2004, it found an enthusiastic enforcer in its new president, Mikheil Saakashvili—a young, intelligent Columbia Law grad who appointed an energetic, technocratic Cabinet, including boy-wonders such as a defense minister who at the age of 29 had to manage a war with Vladimir Putin. Saakashvili speaks excellent English, and once he was elected, he set out to reform his opiate-addicted, economically wrecked country along U.S. lines.

In drug policy, that meant a more robust and aggressive stance toward traffickers. Saakashvili’s government began requiring strict inspections of vehicles and air passengers. By most accounts, re-invigorating the customs inspectors throttled the supply lines enough to take Subutex off the street within a few years.

But the more radical steps involved brutalizing the addicts themselves. Saakashvili mandated as aggressive a drug policy as any country has attempted since Mao Zedong threatened to execute all Chinese opium fiends and “cured” about five million of them overnight. If you think New York’s stop-and-frisk rule is invasive, try Georgia’s: Cops can stop anyone at any time for no reason and force him to urinate into a cup. Fifty-three thousand people were stopped on the street in 2007, or about one in 20 of the young men in Georgia. About a third of those passed dirty urine; first-offenders were levied a fine of several hundred dollars. One more dirty test amounted to a criminal offense.

“There was such an unprecedented drug war,” Otiashvili says. “What was going on—and still goes on—in Georgia doesn’t happen anywhere. No country puts people in the prison for a positive urine test.”

Saakashvili’s government didn’t skimp on punishment, either. “I paid fifty thousand lari [about $30,000],” Pavel says. “A lot of us had to sell our houses, because the alternative was prison.” Pavel lost everything anyway and was jailed for a year. Between 2004 and 2010, the prison population tripled, and Georgia climbed to the number-four position—three positions below the United States—for percentage of citizens behind bars, with about a third of them in for drugs.

The preferred recipe for this cocktail is one part puke to one part Tang.

In jail, the worst addicts exhibited signs of what clinicians call “toxicomania,” which is a self-destructive willingness to eat or inject anything at all, as long as it messes with their heads. But many—including Pavel—cleaned up, at least for a while. There is a myth that opiate withdrawal is physical torture and reduces serious addicts to quivering, sweating messes on the brink of death. In fact, it lasts about two weeks, is no worse than a very bad fever, and has never killed anyone. William Burroughs, who spent two decades on heroin, said that “getting off drugs is not all that difficult. It’s vastly exaggerated—only a month, whatever method is used, a slow withdrawal or whatever, and they’re going to be out of the woods.” For many of the users who went to prison and had no interest in drinking toner or rubbing alcohol, the experience really did help.

When they emerged from their cells in 2010 or so, like bears emerging from their caves in the spring, Subutex had basically disappeared. “For the last two years, I haven’t seen a single tablet of Subutex,” Pavel says. “If you go outside and tell someone you’re looking to buy Subutex, you are never going to find it. And you are probably going to be caught.”

The problem with all this success was that Georgia still had thousands of depressed ex-junkies, and not all were ready to face reality sober. Pavel was one of them.

Instead of retiring his syringe, he injected krokodil, a homebrew so vile that I had to ask him twice to repeat the recipe. It is simple. First get codeine from a pharmacy. Then mix it with toilet-cleaner, red phosphorus (the strike-strips on matchbooks are a good source), and lighter fluid. Voilà, your krokodil is served.

Russian addicts pioneered the use of krokodil, and from there, the devil went down to Georgia. “It is basically a form of suicide,” George Tsereteli, the doctor and politician, says. Krokodil disappears from your system within hours, so it’s hard to catch in a random urine test. (Georgian police still stop about 30,000 people per year.) But the health effects are nonetheless horrific.

Ironically, the opiate that is the active ingredient in krokodil—desomorphine—is fairly safe. It’s the gasoline and drain cleaner that get you. Users find that their skin dies, and their veins rot inside their arms. Their lungs and nervous systems eventually go, too. David Vadachkoria, who runs Tbilisi’s Research Institute on Addiction, told me that the situation is now “very difficult,” because the guys who used to use Subutex and were lightly, reversibly zombified are instead turned into permanent invalids. “They can’t speak, they can’t walk,” he says. “They have Parkinson-like symptoms, and we don’t have anything to do for them.”

“Fifteen years of shooting other drugs weren’t as bad for me as the eight months I spent on krokodil,” Pavel says. Pavel started methadone treatment five months ago and is now on 100 milligrams daily, a medium dose that keeps him off heroin and krokodil but still makes him nostalgic for Subutex. “At least it was pure,” he says. “But it disappeared and got expensive, and krokodil was cheap and easy to get. Getting rid of Subutex was the worst thing the government could do.”

Pavel said he wanted to be free and clean in five months to a year. I would not have bet money either way. If he was desperate enough to inject krokodil just one year ago, his disease must have been profound. And by his own account, he took drugs because he had a miserable life. There’s no reason to think that he’d stop wanting a drug-assisted escape, even after he no longer craved opiates physically.

About 2,000 of Georgia’s addicts are now on methadone, and the clinical director of one of the programs estimated that only 5 percent ever graduate. One unit in Tbilisi, near Pushkin Square, actually uses Subutex, too—effectively weaning addicts off Subutex by giving them Subutex. But the drug is now tightly controlled, and even if every Subutex patient diverted his product to the black market, it couldn’t feed a fraction of Georgia’s latent demand. And that means that the number of Subutex addicts—legal and illegal—in Georgia now might be in the triple digits, when just a few years ago, it was as much as a thousand times higher.

Among experts, there is little doubt that making drugs easier to get makes people use them more, and sometimes a lot more. “It can happen overnight,” says Mark Kleiman, the UCLA professor. “If you find a drug that people like, it’ll spread like wildfire.”

Consider the case of OxyContin, which became known as “hillbilly heroin” after doctors started prescribing it for pain relief and saw it diverted to previously sober addicts in poor communities in Kentucky and West Virginia. “Appalachia simply had never had an opiate problem, because heroin wasn’t available there,” Kleiman says. “People didn’t use it, and since people didn’t use it, nobody sold it. That was a stable equilibrium.” Then OxyContin showed up. “It took about three minutes for people to figure out you could crush that and snort it or shoot it,” Kleiman says. “It shows up in rural Kentucky and they’ve got an injected-opiate problem overnight.”

What’s worse, those markets for OxyContin turned out to survive the busting of prescription-drug rings. In Ohio, in 2012, the Feds stopped a $2.8 billion smuggling operation only to find that, within months, heroin dealers arrived to feed the unmet demand of the OxyContin addicts. Heroin kills, and OxyContin, unless badly mishandled, does not. So as in Georgia, no blessing in the drug war turned out to be unmixed.

Kleiman was recently appointed “pot czar”—he prefers “hemperor”—of Washington state, in charge of advising the government as it implements the state marijuana program that voters mandated last November. In this country, politicians aren’t seriously contemplating legalizing opiates. And marijuana is both slightly less addictive than opiates and infinitely less dangerous (never killing users versus frequently killing them). But the pattern of abuse is similar: Sudden supply shocks, such as the legal availability even of regulated cannabis, have predictable effects on consumption. These effects are often unhealthy—at least in the short term. The semi-legalization of pot in Holland (it’s still illegal, but in the unenforced category the Dutch call gedoogd) caused pot usage to increase there in the years after, although the use has since declined to below-U.S. levels.

The National Institutes of Health believe that about one in ten people who try weed will get hooked on it. By contrast, about 23 percent of heroin users get hooked, and remain so for much, much longer and with much worse effects. Dependence on pot isn’t a minor thing—imagine stalling the careers of a tenth of the U.S. workforce for a year—and we should certainly consider it in the negative side of the ledger when contemplating reform in drug policy.

Georgians, of course, would probably be happy to trade their Subutex problem and its krokodil successor for a pot problem. (In fact, they have plenty of pot already.) But would they trade it for an uninterrupted history of draconian enforcement and no epidemic at all? Quite possibly.

What none of the solutions—whether tending toward radical reform, or severe enforcement—addresses is the impulse that led Pavel to drugs in the first place. He is a lawyer who runs a market stall, a frustrated man who evidently prefers to corrode his veins rather than prolong his misery with sobriety and good health. Ultimately, the solution to the drug problem might be the solution to the problem of life, which is how to navigate our time here with minimal suffering. Unfortunately, the policy that offers that solution will be not a drug policy but an existential one, and it remains as elusive as ever. 

Graeme Wood is a contributing editor at The Atlantic.

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