Treatment works for drug addiction

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Treatment works for drug addiction

BY Dr STEVEN KW CHOW

THE United Nations estimates that there are about 185 million drug abusers worldwide, of which about 15 million are heroin users. Although smaller in numbers compared to other drug users, heroin users contribute to the bulk of public health problems associated with drug addiction, like the 40 million HIV infections worldwide. Heroin addiction is also associated with a significant economic cost to governments – loss of productive population, crime, medical care, and social welfare.

Statistics from the Agensi Anti-Dadah Kebangsaan (AADK) revealed that out of the 10,473 cases recorded from January to March 2005 in Malaysia this year, 46.2% were new addicts and the remaining 53.8% were relapse cases.

The most frequently abused drugs were heroin (36%), morphine (30%), cannabis (23%) and metamphetamine (7%) The Malaysian government currently spends more than RM50mil a year for drug rehabilitation alone. However, current trends indicate that the number of drug users in the country, currently registered at more than 270,000, could reach half a million by 2015, which is the year that the government has vowed to make Malaysia drug-free. Improving access and quality of care There is an urgent need for a concerted nation-wide effort to improve access and the quality of drug addiction treatment in the country. The message from us in the treatment community to the public is that treatment works and that we need to reduce the stigma associated with drug addiction, which hinders a great number of addicts from seeking help. For many years, the “treatment community”, encompassing medical doctors, substance abuse counsellors, psychologists, psychiatrists and social workers, has maintained that drug addiction is a chronic disease. Studies have shown that drug addiction shares many features with other chronic illnesses, including a tendency to run in families (hereditary), and can in fact be treated quite effectively using a holistic, medical approach. Effective medical treatment addresses the multiple needs of the individual and not just drug use. Opiate addiction in Malaysia Up to very recently, heroin has been traditionally the main drug of abuse. The official government statistics indicated 275,499 heroin addicts registered in 2004. WHO estimates that only one in four drug addicts are registered. Thus, the extent of the problem that we may be facing is potentially mind-boggling. Heroin addiction has a major impact on the cost of medical care in Malaysia as exemplified by:

Approximately 77% of all reported HIV cases are secondary to intraveneous drug use (WPRO, 1999)

High incidence of hepatitis C and pulmonary tuberculosis in drug addicts

High cost of current programmes of compulsory drug rehabilitation with high relapse rates. Injecting drugs and needle sharing are major risk behaviours for HIV transmission in drug users (Juita, 1995; Yoong, 1997), which accounts for an estimated 12 to 56% of HIV infections in heroin users (Wang & Ismail, 1998; Lye et al, 1994; Singh et al, 1993), except for sexual transmission, particularly with cross-border unprotected sexual exposure in northern peninsular Malaysia. Thus there is compelling evidence for instituting needle exchange and harm reduction programmes in Malaysia. However it must be remembered that these programmes deal only with one extreme of the spectrum i.e. the end-stage disease scenario. It cannot and was never meant to be the model for a wholesome national programme that should emphasise prevention and early treatment. Treatment for heroin addiction The face of opioid addiction treatment has been changing at a rapid pace with the employment of various new strategies. Newer innovations, particularly community-based treatment programmes, allow more people who are opioid-dependent to have access to the treatment that they need. In Malaysia, drug addiction has been treated with behaviour-based and faith-based programmes. For some drugs, such as heroin, there is also treatment with prescription medications. Treatment must however, go beyond just providing a substitution medication. It must also include the development of job skills, counselling and other ancillary services. In Malaysia, two medications are currently registered for the substitution treatment of heroin dependence, namely buprenorphine and methadone. Methadone works by binding to opiate receptors in the brain to trigger a substitution response (i.e. as an agonist). Buprenorphine on the other hand works in two ways, firstly as a partial agonist and secondly by binding to the receptor itself and actually blocking it from activation by agonists (ie. as an antagonist). With its other action as a partial agonist, buprenorphine activates the receptor but does not cause as much of a physiological change as does a full agonist. Buprenorphine was first marketed for the treatment of heroin dependence in France in 1996, and subsequently followed by other countries. Today, buprenorphine is registered and marketed in 37 countries worldwide, including in all main reference countries (Australia, US, UK and most European countries and in some Asian countries). Ever since its introduction, buprenorphine has been widely accepted worldwide as an effective and a safe option in treating opiate dependence for two reasons. Firstly, buprenorphine, when used correctly, provides a wide safety margin with significantly lower chances for severe overdose effects. It produces little physical dependence or respiratory depression and produces only mild withdrawal symptoms, even if withdrawn abruptly (Fudala et al, 1990; Jasinski Pevnick & Griffith, 1978). Secondly, buprenorphine’s long duration of action allows for flexible, patient-tailored dose administration. This wide safety margin makes buprenorphine suitable for use in new treatment settings, such as an office practice, as well as in the more institution-based traditional opioid treatment programmes. On the community level, treatment with buprenorphine has been shown to reduce the harmful effects of opioid dependence by reducing drug use severity, restoring productivity and social status of patients and decreasing the spread of HIV/AIDS and other infectious diseases (Fhima et al, 2001; Kakko et al, 2003; Mattick et al, 2003). Methadone has been recently launched in Malaysia in a pilot treatment programme at selected treatment centres. The earlier experience of methadone in Malaysia in the early 70s had been disastrous due to widespread abuse of the medication as a result of poor regulation and control. The Buprenorphine experience in Malaysia – challenges to medical treatment The potential for diversion and abuse of these prescription drugs has always been a cause of concern for responsible members of the treatment community. The treatment community’s diligence and accountability in the dispensing of opioids is absolutely crucial in maintaining the security of these treatment drugs and to ensure that they are not abused by unscrupulous parties for mere profit. Treatment clinics and office-based doctors are required to comply with established federal regulations as well as recommended practice guidelines. Additionally, good clinical governance requires the practitioner to institute practices and procedures that will protect against inappropriate or illegal prescribing of opioids. Buprenorphine was introduced in November 2001 in Malaysia, and has been used successfully for the past four years for detoxification and maintenance therapy. On the positive side, the availability of this medication has enabled the hidden heroin addicts to seek community-based treatment in their neighbourhood clinics and to continue to live a productive life. Despite the best of intentions, there have been reported cases of illicit diversion of buprenorphine and injecting of prescribed buprenorphine. Based on experiences in other countries, this undesirable activity is not unexpected in the addict population. Invariably there will be a proportion (up to 25%) of hardcore patients who will abuse their treatment regardless of what medication is used. To curb this problem, strict control measures were instituted in the supply and distribution of buprenorphine. In the past, this has resulted in the disruption of medication supply, which in turn destabilised the treatment environment for patients who were in remission. Destabilisation of the treatment environment provides the ideal environment for relapse and the failure of community-based treatment. In anticipation of this problem, the treatment community has pushed to put in place an on-going integrated programme with the strategy of cultivating the highest level of care in buprenorphine substitution treatment. This programme aims to instil good clinical practice by the medical practitioners, improve counselling skills, encourage family and community support and to educate the public. Newer medications that have additional safeguards against abuse are already in the pipeline, like preparations combining buprenorphine and naloxone (an opiate antagonist). Experiences in other countries have shown their superior efficacy and safety in community-based treatment compared to currently available options. In absolute terms, the number of addicts treated with buprenorphine (estimated at 5,000) is very low compared to the total number of 275,499 registered heroin addicts in Malaysia. There is currently a mismatch between the ability to provide help and the amount of people needing help in community-based treatment. Thus expanding the treatment community and maintaining a stable treatment environment is of paramount importance for implementing a successful community-based treatment programme.

Dr KW Chow is president of the Federation of Private Medical Practitioners Associations Malaysia and founding chairman of DrsWhoCare. This article is contributed by the Federation of Private Medical Practitioners Associations Malaysia. For further information, e-mail starhealth@.... The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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