DRUG AND AIDS IN THAILAND : SAME POLICIES, DIFFERENT LAWS. HOW CAN THEY BE REFORMED TO OBTAIN THE MOST BENEFIT?
Annop Visudhimark M.D. 1997
Department of Medical Services,
Ministry of Public Health

Since 1958, heroin replaced opium to be the principal drug dependence in Thailand and became the prior National policy to control.  The Narcotic Act states that heroin and paraphernalia are illegal. Many situations; purified heroin, a large number of addicts and black market methadone awareness etc, make heroin detoxification be limited within 45 days and methadone should be prescribed by licensed physicians under Medical Practice Law.   In 1984, first AIDS case seen with rapid transmission of HIV to the intravenous drug users. Drug and AIDS policies rise up to higher rank Many programmes implemented together to reduce their spreading. Harm reduction strategies are accepted, but the needle providing and methadone maintenance are not in accordance with the Narcotic Act Some studies show both advantage and weak point of drug related harm reduction. This review suggests of set up the trial studies of various health services relate to the problem strategies by the Government services. The studied outcomes would be the data for Health law reform to obtain their most benefit

1. Background.

Opium smoking has been a drug dependence problem in Thailand for centuries.   To deal with the opium problem, the Government enacted the opium ban law on 9th December 1958 and enforced from 1st January 1959. The opium smokers must by law registered to the Excise Department and sought for treatment in the official treatment center within six months.(1,2) Concurrent to this law, the Government established the opium treatment center in Patumthani , Bangkok suburb. The first discovery of heroin use was described by Dr. P. Norakarnpadoong , the director of the treatment center, since August 1959.(1) This evidence demonstrated the first heroin epidemic in Thailand.

The second heroin epidemic began in 1967, with rapidly spreading in both Bangkok and rural areas. No report explained the cause of this epidemic.(1)

Refer to these heroin epidemics, scarcity of opium might be one among many factors which induced this problem.(2)  The pattern of opium use changed from smoking to injection in some rural areas in the northern region.(3)  The common method of heroin use ; smoking and fume inhaling or chasing the dragon, also changed to injection. Heroin injection which appeared after the heroin epidemic replaced opium smoking to be the significant opiate abuse problem. Nowadays, Thailand Development Research Institute estimated that there were 1.27 million drug abusers on 31st December 1993, among them about 17 and 5 percent were heroin and opium dependents or 220,000 and 64,000 dependents consecutively.(4)  The drug impact on socioeconomic lost leading to be the National policy to control as stated in the Government Security policy on 11th December 1996.5

2. HIV infection among drug abuse population.

The first acquired immunodeficiency syndrome (AIDS) case in Thailand was identified in September 1984. (6,7,8,9) Although it was first found in a homosexual man, but the transmission changed from sexual transmission to blood transmission route and rapidly spread among the intravenous drug users.

The Ministry of Public Health conducted the sentinel surveillance biennially in June and December. The high risk groups, IVDUs included, were sampled in all regions and Bangkok. The pattern of HIV seropositive prevalence reveals a range of about 16 - 42 percent of IVDUs in all regions and the overall country prevalence is quite constant at approximately 37 percent since 1989.(10) The Thanyarak Hospital, the largest drug dependence treatment center, also reported that 33 percent of the admitted IVDIJs were HIV infected.(11) The rapid transmission of HIV rises up AIDS prevention and control policy to higher rank.

3. Drug dependence treatment.

Treatment is one among four National measures to deal with drug dependence problem. The treatment service can be classified into 3 systems ; voluntary system, correctional system for the convicted cases and compulsory system for the identified cases. According to the Narcotic Act, the treatment procedure is divided into 4 phases

1. Pre-admission : to assess both physical and psychosocial causes of dependence ; treatment plan included, within 7 days.

2. Detoxification : to treat physical dependence within 45 days.

3. Rehabilitation : to change the drug habit and to reduce the psychological cause within 180 days.

4. After care : to follow up the client for 1 year.

Each dependent has his own degree of dependence depend upon his underlying health status, type, pattern and duration of drug use. Some have underlying ; both physical and mental, diseases and complications. The treatment services in detoxification phase are not only to detoxify them but also to treat either underlying diseases or dependence complications.   So they should be managed by the licensed physicians under the Medical Practice Law.

4. Harm reduction.

The treatment service has 2 main purposes ; detoxification and relapse prevention. In fact, the number of the dependents who in contact with voluntary treatment service, 60,000 - 80,000 cases a year, is not much in comparison with the total dependent population even the emergence of HIV infection among the injectors make more of them enter treatment programme adding to high relapse rate are two reasons leading harm reduction to be the third treatment purpose other than detoxification and relapse prevention.

Harm reduction aims to reduce the damage produced by a habit which the dependence cannot or will not give up. In case of drug and AIDS, harm reduction means to reduce HIV infection in the dependents especially the IVDUs. Therefore, drug/ AIDS prevention and control usually implement together by means of harm reduction which usually has two goals : (12)

1. Drug - related goal. The ideal goal of drug treatment is to stop using or treated dependents are absolutely cured. In fact, the relapse rate is so high due to the chronicity of disease. So the treatment goal goes to reduce drug harms by educating the hard core dependence not to inject. If still inject, use clean needles and not share with another.

Stop using
===> No injection (Smoking?)
===> Clean needles
===>No sharing

2. Broader goal. Absolutely no harm from drug abuse with good health is the most important target, many education programmes and campaigns focusing on stop or reduce unsafe sex, healthy life style included, are applied.

Various strategies are recommended for implementation to reach both goals.(12,13)

1. Education. For public awareness on drug abuse and AIDS, various education programme have been implemented to the public on hazards of drug abuse especially injection, how to obtain sterile injecting equipment and condom, safe sex, healthy life style etc.

2. Direct action. Due to different socio-cultural causes and drug abuse pattern, many strategies are direct applied to different target groups, treatment motivation, immunization, provision of condom, HIV testing, legislation etc.

5. Policy and Law.

Although the National policies on drug and AIDS are coincide with the acceptance of harm minimization but few constraints found in some strategies due to not in accordance with some law e.g. the Narcotic Act, Medical Practice Law.

1. Methadone Maintenance Programme. The programme concept is long term methadone providing to replace heroin with expect that the addict will stop injection. Owing to methadone administration is medical practice, so it must be prescribed by the license physician. In addition, a large number of the addicts who use purified heroin, plenty of them have the underlying psychosocial cause of heroin addiction which difficult to give up. Long term methadone replace heroin among them without any appropriate intervention to solve their problems will make them still depend on methadone and seems like introduce new drug abuse to the black market. Black market methadone awareness is the reason of the Narcotic Act for not allow the detoxification period longer than 45 days.   However, some studies on long term methadone detoxification (90 days, 120 days and longer) with approval from the Ministry of Public Health reported that the clients still addict to methadone, cannot stop using needle forever but reduce the frequency of injection. In practical point, the hard core addicts can re-regist themselves again to the voluntary treatment programme after passing 45 days. Most of them reported themselves of occasional heroin injection.

2. Needle Exchange programme. This' programme aims to reduce HIV transmission by providing clean needle to the injectors. By the Narcotic Act, needle and syringe are illegal heroin paraphernalia. (14) Anyhow, inexpensive new needles and syringes could be found easily in the drug stores. Just education programmes on sterile injecting equipment to the injectors are effective for obtaining clean needles and syringes by their own expense.

6. Suggestion.

Either drug or AIDS are the significant health problems which have the same goals in prevention and control. Some harm reduction strategies can lower the risk of HIV spreading, in the other hand, improper management will gain the negative drug impact to the society. This study suggests that Governmental Organization should set up the trial studies of various health services related to the drug and AIDS impact e.g.

1. Long term methadone administration: to study the feasibility of long term methadone programme under the appropriate conditions which can reduce the risk of injection and without any negative impact.

2. Needle exchange and outreach programme: even sterile injecting equipment can easily found but it is not accessible in some remote areas. To provide clean needles through some appropriate health services or outreach programme without any hidden purposes. Unintentional impact should be aware. etc.

To avoid illegal implementation all studies ought to be approved by the Ministry of Public Health. The outcome and impact of all studies would be the data for consideration of Health Law reform in order to gain the convenience among the health personnel to deal with both problems.

7. Conclusion.

The rapid spreading of HIV Infection especially among the intravenous drug users in addition with drug epidemic become 2 serious health problems which the Government declared the National Policy on prevention and control. Harm reduction is applied to reduce the HIV spreading among the injectors, but some strategies are not in accordance with the Narcotic Act. The trial studies on long term methadone administration and needle exchange/ outreach programme by the Governmental Organization in order to control some conditions with approval from the Ministry of Public Health are suggested. The impact and outcome would be the data for Health Law reform.

References

1. Poshayachinda, V. Heroin in Thailand. Institute of Health Research, Technical Report, No. DD-1/82 February 1982.

2. Visudhimark, A. Hill Tribe Heroin Addicts in Northern Thailand. In Proceeding of the 9th Conference of the International Federation of NonGovernmental Organizations for the Prevention of Drug & Substance Abuse. Hong Kong, 1988.

3. Visudhimark, A. and Ounachak T. Changing Patterns of Opiate Dependence in Changing Hill Tribal Society. In: Proceedings of the 3rd ASEAN Congress on Psychiatry & Mental Health and 7th ASEAN Forum on Child and Adolescent Psychiatry. Kuala Lumpur, Malaysia, 1991.

4. Thailand Development Research Institute. A study off the number of drug addicts in Thailand. December 1994.

5. National Security Policy number 10.2.1. Government Policy Declaration. 11th December 1996.

6. Panuphak, P. and others. A report of three cases of AIDS in Thailand. Asian Pacific Journal of Allergy and Immunology, vol. 3, 1985, 195-199.

7. Division of AIDS, Department of Communicable Diseases Control, Ministry of Public Health. The AIDS patients. AIDS Newsl. , 2 (11), 1989, 7.

8. Poshyachinda, V. Drugs and AIDS in Southeast-Asia. Forensic Science International, 62, 1993, 15-28.

9. Poshyachinda, V. Drug injecting and HIV infection among the population of drug abusers in Asia. Bulletin on Narcotics, XLV (I) , 1993,77-90.

10. Division of Epidemiology, Ministry of Public Health. Weekly Epidemiological Surveillance Report, 27 (55), 7th June 1996.

11. Thanyarak Hospital Statistical Report FY 1995. Thanyarak Hospital, Department of Medical Services, Ministry of Public Health, 1995.

12. Visudhimark, A. Harm Minimisation of Drug Abuse in Thailand. In Proceedings of the regional conference on Cultural variations in the meaning of Harm minimisation : Their implications for policy and practice in the drug arena. National Center for Research into the Prevention of Drug Abuse, Curtin University, WHO Collaborating Centre for Prevention and Control of Alcohol and Drug Abuse and National Drug and Alcohol Research Centre, University of NSW, Australia. 1996.

13. Department of Health, Scottish Office Home and Health Department, Welsh Office. Report of a Medical Working Group. Drug Misuse and Dependence : Guidelines on Clinical Management. 1991.

14. The Narcotic Act B.E. 2522 (1979) Section 102 , 1979.