Content · 2018. 8. 16. · DRUG ADDICTION IS A COMPLEX ... •Repeatedly incarcerated •Polydrug...

Content

• Methadone : what & why ?

• Outcome over 12 years

• Issues of methadone treatment & men in Malaysia

• Conclusion

INTRODUCTION

◼ Malaysia

◼ Substance use is mainly a problem among men

◼ Implications of substance use :everybody

◼ Estimated 170,000 people inject drug in thecountry

◼ Commonly used illicit substances are heroin,amphetamine, marijuana & designer drugs

◼ Methadone is one of medical treatment for heroinuse

Classification of opioids

Classification Types

Full agonists Heroin, morphine, methadone, codeine

Partial agonists Buprenorphine

Antagonist Naltrexone, naloxone

History of DST in Malaysia

DST is a part of harm reduction approach

taken to reduce drug related harm

• 1995: Naltrexone

• 2001: Buprenorphine

• 2005: Methadone

• 2007: Buprenorphine/Naloxone (Suboxone)

Methadone re classified as Poison

Comparison among DSTs

DST : Benefit

• High rates of retention of patients areachieved and an opportunity is provided forindividuals to deal with major health,psychological, family, housing, employment,financial and legal issues while undergoingtreatment.

• Provides opportunities for early diagnosis ofother health problems, HIV testing andcounseling and referral for additional services.

Methadone

• Used as treatment for opiate dependent since 1970’s

• In Msia: started since 2005 as part of harm reduction strategies against HIV

• Taken daily

• Half life : 16-36 hrs

• Syrup form

• Cheap

Release of dopamine in brain

HypodopaminaemiaPositron emission tomography:• The striatum (which contains

the reward and motor circuitry) shows up as bright red and yellow in the controls (in the left column), indicating numerous dopamine D2 receptors.

• Conversely, the brains of addicted individuals (in the right column) show a less intense signal, indicating lower levels of dopamine D2 receptors.

Pike VW. J Psychopharmacology 1993

This is how opiates activate the reward system using the nucleus accumbens as an example.

Three neurons participate in opiate action; the dopamine terminal, another terminal (on

the right) containing a different neurotransmitter (probably GABA), and the post-synaptic

cell containing dopamine receptors. Opiates bind to opiate receptors (green) on the

neighboring terminal and this sends a signal to the dopamine terminal to release more

dopamine. [One theory is that opiate receptor activation decreases GABA release, which

normally inhibits dopamine release - so dopamine release is increased.]

DRUG ADDICTION IS A COMPLEX ILLNESS

A shift from moral model to disease model

Common features of patients who use illicit drugs:

• Stigmatized• Drug related crimes• Unstable marriage• Unstable economy• Repeatedly incarcerated• Polydrug users / problem with alcohol• Can’t forget the joy of taking drug• Poor coping mechanism• Low self esteem• Low motivation level• Multiple co morbidities

With effective intervention In place.

300,000 HIV/AIDS cases by 2015If no Effective intervention in place

Projection

Of cumulative

HIV/AIDS cases

YEAR

2010 20152005

300,000

100,000

The expectedreduction of

HIV/AIDS cases

1985

HIV/AIDS Projection by 2015, Malaysia

Estimated Prevalence: 1.3% - Estimated PLWHAs: 188,838

2. Screening and medical treatment

4. Needle Syringe Exchange Program (NSEP)5. Safe Sex (Condom use) VCT

COUNCELING

DRUG REHAB

ARV Rx.STD Rx.

SOCIAL WELFARE

HEALTH & MEDICAL CARE

JOB PLACEMENT

COMPONENT OF HARM REDUCTION

IEC

1. Education

3. Methadone Maintenance Therapy (MMT)

DST FACILITIES, MALAYSIA 2017

DST

(Commenced : Oct

2005)

Number of DST Facility (Cumulative by Years)

2011 2012 2013 2014 2015 2016 2017

Hospital 48 49 53 55 55 55 53

Health Clinic 168 203 293 316 359 387 398

G.P (MoH

partnership)24 21 22 24 24 22 22

NADA 32 41 59 58 25* 24 24

Prison 18 18 18 18 18 17 22

Others 2 1 1 1 1 1 1

Total Govt 292 333 446 472 482 506 520

G.P Setting 382 382 365 366 375 401 369

TOTAL 674 715 811 838 857 907 889

Source : Ministry of Health, Malaysia

COVERAGE : DST PATIENTS 2017

DST

(Commenced : Oct

2005)

2011 2012 2013 2014 2015 2016 2017

No. of registered

patient at Govt

Setting (Annual)

5,086 6,801 5,688 4,111 3,710 3,064 2,811

No. of registered

patient at Govt

Setting (Cum)

20,955 27,756 33,444 37,555 41,265 44,329 47,140

No. of registered

patient at GP Setting

(Cum)*

23,257

*

24,324

*

31,805

**

37,261

**44,361 50,616 52,341

TOTAL 44,212 52,080 65,249 74,816 85,626 94,945 99,481

Source : 1. Disease Control Division, MoH Malaysia2. * NDST Report, AMAM3. ** SPIKE System, Pharmaceutical Service Division, MoH Malaysia

Outcome of methadone treatment towards men in Malaysia

(2005-2017)

United Nations Office on Drugs and Crime (UNODC)

Engraved as:

“Presented to Tampin Health Clinic in recognition of its contribution to promoting community based drug dependence treatment in Southeast Asia

July 2012 “

Changes in HIV landscape, Malaysia 2000 - 2017

Source: HIV/STI /Hep C Sector, Division of Disease Control, Ministry of Health Malaysia

HIV PREVALENCE

AMONG PWID (IBBS)

2009 22.1%

2012 18.9%

2014 16.3%

2017 13.4%

REPORTED HIV CASES ATTRIBUTED TO IDU, MALAYSIA 2000 - 2017

3,815

4,724

5,176

4,796

4,478

4,038

3,127

2,601

2,113

1,699 1,7331,348

1,014728 680 561

377115

74.779.6

74.2

70.6

69.7

66

53.657.3 57.2

55.2

47.6

38.729.5

21.5 19.316.8

11.13.44

0

10

20

30

40

50

60

70

80

90

0

1,000

2,000

3,000

4,000

5,000

6,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Notif ication rateNo

Year

HIV IDU

Notification rate

Source : MoH Malaysia

MALAYSIAN METHADONE TREATMENT OUTCOME STUDY (MyTOS) 2016

• NMRR: 13-1270-18045 ( 15th May 2014)• MRG-MOH-2014-10 (28th Aug 2014)

Socio demographic characteristic Count %

Sex (n=3254)

Male 3223 99.0

Female 31 1.0

Ethnicity (n=3254)

Malay 2862 85.9

Chinese 261 9.3

Indian 116 4.3

Others 15 0.2

Marital Status(n=3254)

Married 1420 42

Widowed 36 1.0

Divorced 230 7.6

Separated 16 0.5

Cohabiting 3 0.1

Never Married 1549 48.8

MyTOS 2016

Status

Status Count Estimated

population

% Prevalence 95% CI

Lower Upper

Dead 251 2373 8.6 6.8 10.8

Defaulted 984 8030 29.2 26 32.4

Transferred 546 4831 17.5 14.6 20.8

Active 1234 10243 37.1 33.7 40.7

Terminated voluntarily

Terminated involuntarily

221

18

1972

138

7.1

0.5

4.9

0.2

10.3

1.1

Status ( n=3254) Count Estimated

population

%

Prevalence

95% CI

Lower Upper

Dead 251 2373 8.6 6.8 10.8

Defaulted 984 8030 29.2 26 32.4

Transferred 546 4831 17.5 14.6 20.8

Active 1234 10243 37.1 33.7 40.7

Terminated voluntarily

Terminated

involuntarily

221

18

1972

138

7.1

0.5

4.9

0.2

10.3

1.1

HIV risk, crime & health

Items

n= 779

Mean ± SD Mean

difference ± SE

(before vs

after)

95% CI t P

HIV Risks 6.22 ±

7.24

2.65 ± 4.27 3.56 ± 0.23 3.12 4.00 15.77 <0.001

Crime 0.30 ±

1.10

0.03 ± 0.28 0.30 ± 0.03 0.24 0.37 9.11 <0.001

Health

score

3.94 ±

4.50

2.22 ± 3.09 1.73 ± 0.13 1.47 1.98 13.37 <0.001

Blood borne viruses infectionBBV n Baseline Current

Positive

n (%)

Negative

n (%)

Positive

n (%)

Negative

n (%)

HIV 1200 162 (13.5) 1038 (86.5) 168 (14.0) 1032 (86.0)

Hep B 1183 59 (5.0) 1124 (95.0) 62 (5.2) 1121 (94.8)

Hep C 1088 686 (63.1) 402 (36.9) 703 (64.6) 385 (35.4)

Drug / substans use

Items

n= 779

Mean ± SD Mean difference ±

SE

(before vs after)

95% CI t P

Before After Min Max

Heroin 2.70 ± 2.38 0.003 ± 0.06 2.69 ± 0.08 2.53 2.86 31.62 <0.001

Other opiate 0.05 ± 0.43 0.00 ± 0.00 0.05 ± 0.02 0.02 0.08 3.01 0.002

Alcohol 0.04 ± 0.58 0.00 ± 0.04 0.04 ± 0.02 0.00 0.08 1.99 0.046

Marijuana 0.01 ± 0.26 0.00 ± 0.00 0.01 ± 0.00 0.00 0.03 1.36 0.17

Tranquilizer 0.50 ± 0.68 0.00 ± 0.00 0.05 ± 0.02 0.00 0.10 2.02 0.14

Hallucinogen 0.02 ± 0.24 0.00 ± 0.00 0.02 ± 0.00 0.00 0.36 2.24 0.03

Tobacco 9.53 ± 8.58 0.31 ± 2.05 9.22 ± 0.31 8.61 9.82 30.03 <0.001

Incarceration

History Before MMT

n (%)

After MMT

n (%)

Locked –up(n=868)

Yes 506(58.3) 218(25.1)

No 362(41.7) 650(74.9)

Imprisoned(n=846)

Yes 482 (57) 77 (9.1)

No 364 (43) 769 (90.9)

Involuntary rehabilitation centre(n=831)

Yes 229 (27.6) 13 (1.6)

No 602 (72.4) 818 (98.4)

Incarceration(imprisoned & Involuntary

rehabilitation centre)(n=1234)

Yes 736 (59.6) 93 (7.5)

No 498 (40.4) 1141 (92.5)

Quality of LifeVariable

n= 905

Mean ± SD 95% CI t P

Before After Min Max

Physical 54.42±15.00 67.18±14.63 -13.89 -11.61 -21.90 <0.001

Psychological 51.06±15.65 66.54±14.81 -16.67 -14.29 -25.4 <0.001

Social 52.79±17.54 65.87±17.14 -14.38 -11.77 -19.65 <0.001

Environmental 50.36±14.52 64.48±15.25 -15.21 -13.03 -25.38 <0.001

Patient’s perception towards MMT

26.8%

61.9%

6%

3.1%2.3%

Strongly agree

Agree

Not sure

Disagree

Strongly disagree

Question:

In MMT, you received assistance that

Issues regarding methadone treatment

• Side effects

• Drug-drug interaction

• Stigma

• Long term treatment for chronic disease

• Existing drug law

• Insufficient resources to manage behaviour & fulfilling their psychosocial & spiritual needs

• Multiple difficult to meet needs

MyTOS2016

Drug-Drug Interaction

ARV TB

Needs that are to be addressed in order to stabilize drug addicts

• These needs are multiple, complex and difficult to meet:

- Food - Addiction issues - Medical illnesses

- Shelter - other substances co dependency

- Occupation - Stigma - HIV -Hep B - Hep C

- Family - Depression - Anxiety - Psychosis

- Developing self confidence - to solve legal action

- Finances - Warts - valvular heart disease - DVT

- Self believe and trust by family and the community

- Getting follow up treatment - STIs - TB - peacefulness etc etc etcetc etc etc etc etc etc etc etc etc etc etc etc

Conclusion

• Cost effective treatment

• Protect from further life complications

• Good outcome for patient, family & comunity

• Very little side effects