“Due to problems with addicts, citizens are moving out of Omera Stupca Street” and “There has been less crime since the Addiction Counselling Centre opened” are the headlines of newspaper articles pasted on the front door of the Substitution Therapy Department of the Sarajevo Canton Institute for Alcoholism and Substance Abuse. These headlines are the first thing that about 400 patients, former heroin addicts, see as they come to the facility for therapy. Newspaper articles are there for a reason. They warn patients of the discontent of the local population which has been smouldering for the 17 years since the department’s establishment.

 

Opioid substitution therapy (OST) is the first-choice method in the treatment of heroin addicts which is administered to more than 60 per cent of those seeking treatment. The therapy involves daily controlled administration of the drug under supervision of healthcare practitioners. Methadone, Buprenorphine and Suboxone are used in therapy, drugs that affect natural opiate receptors in the brain, thereby neutralising the craving for drugs. This method was first introduced in Bosnia and Herzegovina in 1989 and has been applied at the Sarajevo Canton Institute for Alcoholism and Substance Abuse since 2002 when the Department for Opioid Substitution Therapy Programmes was established.

 

Approximately 400 former addicts are currently being treated in Sarajevo Canton at the Department for Opioid Substitution Therapy Programmes of the Sarajevo Canton Institute for Alcoholism and Substance Abuse. Some of them receive therapy daily, while a number of stable patients come for therapy two to three times a week. This is the only dislocated department of the Institute and is found in Omera Stupca Street in the Centar Municipality, while the Institute is located at the Jagomir site in Sarajevo. More than 200 patients pay daily visits to the Department – better known to the public as the Methadone Centre.

 

There have been issues with the local population since the establishment of the Department. For about 17 years, the local population has been demanding its relocation. Every few years, the issue of the relocation of the Methadone Centre becomes a topic in the media and the public. At the beginning of October this year, nine days before the start of the official election campaign, the citizens requested the Centar Municipality, on whose territory the OST Department is located, to relocate the centre.

 

“The Centar Municipality also finds that such an institute cannot and must not be located in an urban environment, and therefore we again appeal to the representatives of the Sarajevo Canton Ministry of Health, who are competent for this institution, to find an appropriate place for its relocation,” the then Mayor of the Municipality of Centar Nedžad Ajnadžić said, who was again a mayoral candidate in the municipal elections.

 

The media have addressed this topic every time citizens asked for the relocation of the so-called Methadone Centre, by mainly conveying the statements and demands of citizens. Shortly after publishing texts with the opinions of the citizens, new texts would follow mainly with the reactions of the Institute’s management. The Dnevni Avaz texts, pasted on the front door of the Department, are the best illustration of this media reporting.

 

The text entitled “Locals are calling for relocation of the Addiction Counselling Centre: due to problems with addicts, citizens are moving out of Omera Stupca Street”, was released at the end of September 2018. The text points out the demands of the citizens for the relocation of the Institute and the difficulties faced by the residents of that street. Among other things, the text notes that “parents are afraid to let their children play outside” and journalists further conclude that “the gravity of the situation has been confirmed by a resident who told us that some of her neighbours have moved out of the street precisely because of the problems they have with the addicts who come here”. The statement of “a tenant” was also used for the text headline. The text further states that the Centar Municipality was contacted, whereas the response of the Ministry of Health delivered to the Municipality was published. The text does not state whether the Sarajevo Canton Institute for Alcoholism and Substance Abuse was contacted or whether patients coming for treatment were interviewed.

 

The second text entitled “From the Institute for Alcoholism and Substance Abuse against the petition of locals: there has been less crime since the Addiction Counselling Centre opened” was published three days later and was the response of the Director of the Sarajevo Canton Institute for Alcoholism and Substance Abuse. The text states that the Institute protests against local citizens’ petition “who do not choose the means to promote stigmatisation and discrimination against mentally ill people” and further reads that “the citizens of this local community protested even on the first day after the opening of the Methadone Therapy Programme Counselling Centre” and that they never officially contacted the Institution.

 

In the same year, the media reported on this topic mainly citing the views of citizens who signed the petition and allegations from the response of the Director of the Institute. The public did not have the opportunity to read about personal experiences of citizens or patients treated there. The same issue was raised again in the media just before the local elections this year. When the Centar Municipality announced a new request to relocate the Institute, nine web portals based in Sarajevo, including one of the largest news agencies and the web portal of the public service media, reported on this. The Centar Municipality press release, in which the then Mayor and mayoral candidate in the local elections (who failed to win a new mandate since) states that he supports the citizens’ demands for relocation and offers help to relocate the Institute, was reported by the media almost without any edit or additional information.

 

Director of the Sarajevo Canton Institute for Alcoholism and Substance Abuse, Nermana Mehić Basara, stated in response to our inquiry that she was unable to make a comment due to health issues, but also that the topic can wait as it constitutes an old problem revisited yearly.

 

“Untrue and unnecessary image of a conflict between the local community of Crni Vrh and the Institute is being created in the public, which is not in the interest of anyone and especially not of our patients, the citizens of this city, of whom there are about 100 from the Centar Municipality”, Nermana Mehić Basara said.

 

Every year, the reports of the Institution reiterate the problem of the Substitution Therapy Department being overburdened and call for new treatment points to be opened in the city where patients can receive therapy. Currently, there are about 400 patients from the Canton who are receiving opioid substitution therapy at the Institute, although the Methadone Centre was planned for about 100 patients.

The President of the Local Community Council of Crni vrh - Gorica, Darko Kalaš, said that a common solution to the problem will hardly be reached because citizens do not want the number of patients to be reduced – they want a complete relocation of the Institute from Omera Stupca Street. Darko Kalaš added that the only acceptable solution for citizens is the one agreed at the meeting in the Sarajevo Canton Ministry of Health in December last year.

 

“The Sarajevo Canton Community Health Centre proposed two sites to move the Centre – the former Community Health Centres in Kumrovec and Saraj polje. The conclusion was not reached, the government fell, a new government was formed, and none of this was implemented. Then the pandemic arrived in March and we did not insist on this, but as the pandemic lasts longer than expected, we decided to send a letter reminding the new government, the Prime Minister and the new Minister of Health of this agreement and request for this conclusion to be implemented. Now, this government is no longer stable and we expect its change; there is no Minister of Health, just the Acting Minister, [...] the pandemic is not coming to an end, and this issue is still smouldering”, Darko Kalaš said.

 

Problems with the local population are not without effect on the Institute’s patients. We visited the Institute with a few of them on the days when they receive therapy. They did not want us to reveal their identities because they felt they had been stigmatised enough. As for the local population, the biggest problem for patients is the location of the Institute.

“I understand that people are afraid, it is enough for 500 strangers to walk through the street every day – and these are people protagonists of the worst stories and unfortunately many of them did do the things people talk about, but I would not say any of them did anything in the surrounding of the Centre. We are all aware that this is the only place that offers us help, and if we mess up, it is going to put us all in trouble, not just one person. What I saw is that people are coming to get therapy as soon as they can, because when they get it, nobody wants problems”, one of the Institute’s patients said.

This problem came under the spotlight during the coronavirus pandemic when public transport stopped. Some patients live more than 20 kilometres away from the Institute, most of them are unemployed and of low socio-economic status.

“We live on charity”, they say, because most of them do not have a job, live with their parents or work as daily wage earners when one of their relatives or friends calls them.

 

“When I started treatment, my family members were my only support, and I did not tell many friends that I am undergoing treatment because as soon as you mention treatment and addiction, you become a drug user, a junkie and drug addict. You start losing friends and people who can offer you a job opportunity, you are only left with people who may give you a chance to make money, but illegally. It is very hard to get back on your feet because everyone is holding you back and you rarely get any positive stimulus”, said one of the Institute’s patients we talked with.

 

Patients treated at the Methadone Centre believe that allowing stable patients to receive therapy at a local outpatient clinic or community health centre could solve both the problems of the local population and the problems of patients who reside not only in the centre of Sarajevo but all over the Canton.

 

“How can we get someone back to normal life and re-socialised if there are no centres like this because no one else will get their hands dirty and try to help, even worse, they run away from you because they do not want to be seen with you. By opening these centres in every municipality, outpatient clinic or community health centre, we would stop going to one place. But I think it would mean a lot more, people could get to know them and remove the stigma attached to those who are really in trouble. A lot of patients see it as an illness and want to treat it”, said one of the patients we spoke to.

The example of the Zenica-Doboj Canton Institute for Alcoholism and Substance Abuse shows that treatment organisation in local outpatient clinics or community health centres is not impossible. For 15 years, this Institute has been the only institution in BiH to decentralise substitution therapy and is the only institution that allows a patient to have access to such medical service in their respective municipality. Patient examinations, testing and administration of substitution therapy are conducted in eight additional outpatient clinics apart from Zenica, where the Institute is located – nine places in total provide substitution therapy. Methadone outpatient clinics operate in Zenica, Visoko, Breza, Kakanj, Vareš, Doboj-Jug, Tešanj and Maglaj.

 

Mirnes Telalović, Assistant Director for Quality and Services of the Zenica-Doboj Canton Institute for Alcoholism and Substance Abuse, said that at the very beginning of the Institute’s development they recognised a problem of psychoactive substance addicts, due to their unfavourable economic, social and health condition, not being able to come to one central outpatient clinic due to the number of municipalities and the size of the Canton.

 

“In cooperation with local health centres, we have organised the work and presence of the Institute’s expert team in all municipalities of the Canton where there is an addict who is willing to receive treatment and professional assistance of the Institute. The expert team consists of a doctor specialist, a graduate social worker, a graduate psychologist and a medical technician. In this way, every week (Tuesdays and Thursdays) the Institute’s expert team is present in all municipalities of the Canton in order to provide support for patients in treatment. In addition to ‘field’ treatment, we also provide assistance in implementation of the imposed measures for compulsory treatment, we work with families, assist in implementation of individual and group socio-therapy, and work with families of individuals being treated, which is also compulsory”, Mirnes Telalović said.

 

There were no issues with the local population, Mirnes Telalović said and added that they work very hard on education and prevention.

 

“We did it in such a way that the management of the Institute first presented its model to the competent authorities and representatives of local authorities, directors of health and social institutions, we presented the importance and benefits for patients/addicts who want treatment, but also for the local community. The Department for Prevention designs and implements prevention programmes that promote healthy lifestyles and the importance of treatment for people who have addiction problems. We are present in primary and secondary schools and universities, as well as religious institutions, and we work with parents through school parent councils. In this way, local communities are aware of the benefits of such programmes. Indeed, in the last 15 years that we have been working on this model, we have not had a single negative event, on the contrary, we have had only positive reactions. Cooperation is fair and professional, both with local police authorities, mayors and other relevant institutions. We have open lines every day for consultation, problem-solving and system improvement”, Mirnes Telalović said.

 

The answer to the question why the “Zenica model” is not implemented at the Sarajevo Institute when it works so well can be found in the work reports of the Sarajevo Canton Institute for Alcoholism and Substance Abuse.

 

The Sarajevo Canton Institute for Alcoholism and Substance Abuse has been warning the competent institutions for years that a decentralised model of opiate substitution therapy is necessary. Not only to reduce the burden on the existing facility but also to respect patients/users’ right to a service closest to the place of residence, which is in line with the concept of “Community Mental Health” that has been implemented in Bosnia and Herzegovina since the end of the war in 1996 as a result of serious and demanding reform of the mental healthcare system through community service provision. 

 

Although the Expert Council and the Management of the Institute have repeatedly launched initiatives with the competent institutions to reduce the burden on the OST department, no further support was received for the opening of additional treatment points in the city, apart from the declarative one.