Making Drug Treatment Work Opportunities and Challenges Towards an Evidence and Rights-Based Approach Making Drug Treatment Work Opportunities and Challenges Towards an Evidence and Rights-Based Approach Martin P Wegman, Frederick L Altice, Sangeeth Kaur, Vanesa Rajandaran, Sutayut Osornprasop, David Wilson, David P Wilson, Adeeba Kamarulzaman Acknowledgements The report is part of the World Bank’s Advisory Services and Analytics for Malaysia under HIV Implementation Support in the East Asia and the Pacific region (P160428). The report preparation was under the overall guidance and supervision of Dr. Sutayut Osornprasop (Senior Human Development Specialist) and Dr. David Wilson (Program Director) of the World Bank and Professor Adeeba Kamarulzaman and Dr. Rumana Saifi of the University of Malaya. We would like to express our gratitude to the Infectious Disease Control Division, Ministry of Health (MoH) and National Anti-Drugs Agency (AADK), Malaysia for their contributions to this research. Funding for this research was provided by the World Bank, Malaysian Ministry of Education High Impact Research Grant (HIRGA E000001- 20001), University of Malaya Research Grant (RP009A), National Institute of Mental Health for career development (F30MH105153), National Institute on Drug Abuse for research (R01 DA025943 and R01 DA041271) and career development (K24 DA017072), and Doris Duke Charitable Foundation through a grant supporting the Doris Duke International Clinical Research Fellows Program at Yale University School of Medicine. The team would like to appreciate valuable suggestions from the following technical peer reviewers: Robert Oelrichs, Ernest Massiah, and Fernando Lavadenz. We thank the participants in this study; the staff at Malaysian PUSPEN and Cure & Care facilities; research team and the administrative staff at the Centre of Excellence for Research in AIDS (CERiA). Last but not the least, we thank the World Bank’s Southeast Asia Country Management Unit, Health, Nutrition, Population Global Practice, and the communication team from World Bank’s Malaysia office and Thailand office. The content of this report is solely the responsibility of the authors and does not necessarily represent the official views of the funders. 2 Making Drug Treatment Work: Opportunities and Challenges Towards an Evidence and Rights-Based Approach Table of Contents Acknowledgements 2 Summary 4 Background 4 Methods 4 Findings and Conclusion 4 Background 5 Methods 5 Study Design 5 Participants in the Study 6 Data 6 Findings and Conclusion 6 References 10 Making Drug Treatment Work: Opportunities and Challenges Towards an Evidence and Rights-Based Approach 3 Differences in drug relapse rates between patients from compulsory drug detention centers vs voluntary drug treatment centers in Malaysia Summary Background Compulsory drug detention centers (CDDCs) are common throughout Asia. However, medical treatments for substance use disorders, such as opioid agonist treatment (OAT), are generally unavailable in these settings. In this report, we compare the effectiveness of CDDCs with voluntary drug treatment centers (VTCs) offering OAT in Malaysia. Positive urine drug testing (UDT) after release confirmed opioid relapse in both groups. Specifically, we measure the timing of relapse, i.e., we compare when patients that have been discharged from CDDCs and VTCs relapse to opioid. Methods We conducted a study on opioid dependent individuals from Malaysian CDDCs and VTCs from August 2012 to September 2014. Baseline (at the starting point of the study) and semi-monthly behavioral assessments and UDTs were conducted for up to one year after release/discharge. Relapse rates between the groups were compared using advanced statistical analysis. Findings and Conclusion Screening occurred in 168 CDDC attendees and 113 VTC in-patients, with 89 (CDDC) and 95 (VTC) of these individuals, respectively, having a baseline interview and at least one UDT. We found that opioid-dependent persons that have been released from CDDCs relapse to opioid use significantly faster than those from VTC services. This suggests the services provided by CDDCs have little role in the treatment of opioid use disorders. 4 Making Drug Treatment Work: Opportunities and Challenges Towards an Evidence and Rights-Based Approach Background Criminalization of drug possession and use is common worldwide with many Asian countries confining people who use drugs (PWUDs), or those suspected of using illicit drugs, in specialized facilities called compulsory drug detention centers (CDDCs).1-3 In South and SouthEast Asia, CDDCs continue to operate and now detain more than 400,000 individuals in over 1,000 facilities annually.6,7 Grounds for detention in CDDCs range from positive urine drug testing (UDT) to suspicion of illicit drug use.8,9 Medical therapies for treating substance use disorders, such as opioid-agonist treatment (OAT), are unavailable in CDDCs. Instead, educational and job skills programs, and physical education are among the approaches often utilized.8,10,11 Although it is argued that CDDCs are a key component to a comprehensive response to opioid dependence, and serve to balance the individual’s needs for rehabilitation with the right to safety for their family and community12, there have been few formal evaluations of CDDCs. A recent study on drug detention centers that included compulsory inpatient and outpatient treatment approaches showed little evidence that compulsory drug treatment is effective in promoting abstention from drug use or in reducing criminal recidivism. CDDCs were first introduced in 1978 in response to a growing heroin epidemic in Malaysia and are operated by the National Anti-Drug Agency (NADA). In 2010, 28 detention facilities housed nearly 7,000 individuals. According to national drug control laws, individuals who screen positive on urine drug testing (UDT) for any illicit substance and deemed by a government medical officer to be drug-dependent, are mandated to two years of detention and remain under community supervision for another two years following release.13 Although the Malaysian government shifted from implementing only punitive drug control measures to implementation of harm reduction initiatives, including needle and syringe programs and some OAT programs beginning in 2005,13-15 CDDCs initially remained central to drug control efforts.16 Expansion of community-based OAT by the Ministry of Health Malaysia and prison-based OAT, and recognition that these programs were effective eventually led to a major policy shift by NADA which began to recognize the role of OAT in substance use disorders in 2010. Several of the CDDCs were transformed to voluntary drug treatment facilities as pilot activities, called ‘Cure and Care’ centers, which provide methadone in addition to psychosocial interventions, recreational programming, and vocational training, among other activities.17-19 This study was designed to examine the drug use, health and social outcomes for opioid- dependent persons in Malaysia who were recently released from a CDDC versus those discharged from a voluntary drug treatment center (VTCs). In this analysis, we compare the timing and occurrence of UDT- confirmed opioid and other illicit-drug relapse between the two groups. Methods Study Design We compared individuals from two drug treatment settings: Malaysian CDDCs and VTCs. Baseline and monthly behavioral assessments were conducted along with UDT at baseline and at months 1, 3, 6, 9, and 12 post-release or post-discharge from CDDCs and VTCs. Also, HIV testing was conducted at months 1, 3, 6, 9, and 12 post release or post-discharge. The study was approved by the Medical Ethics Board of University of Malaya Medical Centre and the Yale University Human Investigation Committee; approval was also granted by the National Anti Drug Agency (NADA). Making Drug Treatment Work: Opportunities and Challenges Towards an Evidence and Rights-Based Approach 5 Participants in the Study The study participants were 18 years or above, could provide consent for the study, met criteria for opioid dependence using the Rapid Opioid Dependence Screen (RODS) 21 and intending to live in Klang Valley. Those in CDDCs were receiving mandatory rehabilitation programs that included individual, group and family counseling sessions, spiritual programs, physical training such as marching exercises and vocational training for commercial production like farming or electronics. OAT was not available to these individuals. Individuals enrolled from the VTC were those who were seeking OAT enrollment voluntarily. From August 2012 to September 2014, trained research assistants recruited eligible participants at three VTCs providing methadone maintenance therapy in Greater Kuala Lumpur and at six CDDCs. More CDDC than VTC sites were selected due to excess loss of participants from the time of screening to recruitment. Data Baseline and follow-up interviews collected information on participants’ age, gender, ethnicity, education, marital status, housing status, employment, income, incarceration/detention history, lifetime and recent drug use history, addiction severity 22 , opioid dependence and abuse 23 opioid cravings, motivation to seek addiction treatment 24 , HIV testing and treatment history, social support25 , and drug and sex-related HIV risk behaviors. Research assistants supervised and recorded UDTs for 5 metabolites: opioids, methamphetamines, benzodiazepines, methadone and buprenorphine using a custom RapiDip InstaTest (Cortez Diagnostics, Inc: California, USA). Findings and Conclusion Between August 2012 and September 2014, opioid-dependent individuals were assessed in Malaysian CDDCs (N=168) and in inpatient units of Malaysian VTCs (N=113), with 98 in both groups completing baseline interviews and 89 (CDDC) and 95 (VTC) of these individuals, respectively, having at least one subsequent UDT. Loss of participants was due to inability to locate participants (including early release or discharge) and absence of communication with the study team. Around 50 percent of the participants in each group completed the assessments at month three and one-quarter to one-third at month 12. While we looked at the background characteristics for each group, CDDC participants were older, had higher education levels, were incarcerated more, were less likely to have injected opioids, and were less likely to be making changes toward addressing their recovery. Table 1 describes background characteristics for each group. The participants in both groups looked similar except that CDDC participants were older, had higher education levels, were incarcerated more, were less likely to have injected opioids, and were less likely to be making changes toward addressing their recovery. 6 Making Drug Treatment Work: Opportunities and Challenges Towards an Evidence and Rights-Based Approach TABLE 1: Background characteristics of the participants Compulsory Drug Voluntary Detention Centers Treatment Centers (number of participants = 89) (number of participants = 95) Average Age 39 37 Ethnicity Malay 65 (73.0%) 67 (70.5%) Chinese 9 (10.1%) 11 (11.6%) Indian 15 (16.9%) 17 (17.9%) Completed secondary school Yes 58 (65.2%) 46 (48.4%) No 31 (34.8%) 49 (51.6%) Married Yes 68 (76.4%) 80 (84.2%) No 21 (23.6%) 15 (15.8%) Previous housing type Permanent 28 (32.2%) 25 (26.3%) Temporary 59 (67.8%) 70 (73.7%) Times imprisoned (average) 3 3 Times in lockup/jail (average) 7 5 Times detained in CDDC (average) 1 1 Age of first drug use (years) 18 18 Drug of choice Other 5 (5.7%) 12 (12.6%) Heroin 82 (94.3%) 83 (87.4%) Years of heroin use 16 13 Daily use of heroin before entering facility No 14 (16.3%) 11 (12.5%) Yes 72 (83.7%) 77 (87.5%) Drug use severity Low or Moderate 19 (21.3%) 14 (15.1%) Substantial 59 (66.3%) 65 (69.9%) Severe 11 (12.4%) 14 (15.1%) Opiate cravings (scale of 0-10) 3 3 Ever injected drugs No 51 (56.0% 40 (44.0%) Yes 60 (68.2%) 28 (31.8%) Making Drug Treatment Work: Opportunities and Challenges Towards an Evidence and Rights-Based Approach 7 Compulsory Drug Voluntary Detention Centers Treatment Centers (number of participants = 89) (number of participants = 95) Alcohol use (lifetime) No 17 (19.1%) 25 (26.3%) Yes 72 (80.9%) 70 (73.7%) Non-heroin opiate use (lifetime) No 73 (82.0%) 76 (80.0%) Yes 16 (18.0%) 19 (20.0%) Benzodiazepine use No 74 (83.1%) 79 (83.2%) Yes 15 (16.9%) 16 (16.8%) Stimulant use (lifetime) No 28 (31.5%) 27 (28.4%) Yes 61 (68.5%) 68 (71.6%) Use of >1 drug at same time (lifetime) No 40 (44.9%) 52 (55.9%) Yes 49 (55.1%) 41 (44.1%) Ever received buprenorphine treatment No 78 (87.6%) 73 (86.9%) Yes 11 (12.4%) 11 (13.1%) Recent buprenorphine treatment No 87 (97.8%) 84 (100.0%) Yes 2 (2.2%) 0 (0.0%) Recent emergent/urgent care No 83 (94.3%) 89 (93.7%) Yes 5 (5.7%) 6 (6.3%) Ever tested for HIV No 7 (8.0%) 16 (17.8%) Yes 81 (92.0%) 74 (82.2%) HIV test result HIV-negative 72 (83.7%) 61 (68.5%) HIV-positive 5 (5.8%) 2 (2.2%) Unknown 9 (10.5%) 26 (29.2%) As mentioned, we compared post-release drug use outcomes for people who were admitted to CDDCs for rehabilitation with participants of VTCs. We found, opioid-dependent participants released from CDDCs had 6 times higher chances of relapse to both opioids or any-illicit-drug post-release, compared to individuals released from VTCs in Malaysia. Not only did we find that opioid dependent persons in CDDCs relapse to opioid use markedly faster than those exposed to VTC services, but relapse to opioid use is rapid after release from CDDCs, suggesting CDDCs might have little role in the treatment of opioid use disorders. 8 Making Drug Treatment Work: Opportunities and Challenges Towards an Evidence and Rights-Based Approach FIGURE 1: A graphical presentation on relapse rates and time of relapse 100% 90% Puspen Arm 80% 70% 65% 83% Percent Relapse 60% 50% Tested positive for substances other than methadone 40% 30% C&C Arm 6% 20% 14% 10% 0% 0 0.5 1 1.5 2 2.5 3 3.5 Months Figure 1 compares participants released/discharged from CDDCs and VTCs in terms of opioid relapse. The vertical axis shows percentage of participants who had opioid relapse, whereas the horizontal axis shows the time of relapse after release/discharged. The upper line in the figure shows relapse rates among CDDC participants and the lower line shows relapse rates among VTC participants. In the first month after release, 6 percent of the VTC patients relapsed to opioid, in contrast to 65 percent of CDDC participants. In month 3, 14 percent of the patients from VTCs experienced opioid-relapse; this was 83 percent for CDDC patients. This also suggests the first month after release as the most crucial phase for patients in both groups. Such findings support nascent policy modifications in Southeast Asia that have transformed CDDCs to VTCs,7 where evidence-based treatments like OAT are made available for individuals who meet criteria for opioid use disorders. These striking findings are also urgently needed in the context of recent developments in Malaysia where VTCs are being suspended or reverted to closed settings, in the absence of evidence of benefit.4,34,35 Our results support international calls for all countries in Asia that support CDDCs to scale-up evidence-based services provided by VTCs, including treatments like OAT that can be accessed voluntarily and made potentially available to others as part of an alternative to an incarceration strategy. Making Drug Treatment Work: Opportunities and Challenges Towards an Evidence and Rights-Based Approach 9 References 1. United Nations Office on Drugs and Crime, Economic and Social Commission for Asia and the Pacific, Joint United Nations Programme on HIV/AIDS. Report of the Regional Consultation on Compulsory Centres for Drug Users in Asia and the Pacific. Bangkok, 2010. 2. Jürgens R, Csete J, Amon JJ, Baral S, Beyrer C. People who use drugs, HIV, and human rights. 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