In their own voices: Breaking the vicious cycle of addiction, treatment and criminal justice among people who inject drugs in Ukraine

Aims: To understand how perceived law enforcement policies and practices contribute to the low rates of utilisation of opioid agonist therapies (OAT) like methadone and buprenorphine among people who inject drugs (PWIDs) in Ukraine. Methods: Qualitative data from 25 focus groups (FGs) with 199 opioid-dependent PWIDs in Ukraine examined domains related to lived or learned experiences with OAT, police, arrest, incarceration and criminal activity and were analysed using grounded theory principles. Findings: Most participants were male (66%), in their late 30s, and previously incarcerated (85%), mainly for drug-related activities. When imprisoned, PWIDs perceived themselves as being "addiction-free". After prison-release, the confluence of police surveillance and societal stress contributed to participants' drug use relapse, perpetuating a cycle of searching for money and drugs, followed by re-arrest and re-incarceration. Fear of police and arrest both facilitated OAT entry and simultaneously contributed to avoiding OAT since system-level requirements identified OAT clients as targets for police harassment. OAT represents an evidence-based option to "break the cycle"; however, law enforcement practices still thwart OAT capacity to improve individual and public health. Conclusion: In the absence of structural changes in law enforcement policies and practices in Ukraine, PWIDs will continue to avoid OAT and perpetuate the addiction cycle with high imprisonment rates.