drug treatment in myanmar - mohs

DrugTreatmentinMyanmar

NandaMyo Aung WanDrugTreatmentandResearchUnit

MinistryofHealthandSports

5th June,2019Naypyitaw

outline• Background• Majorandminordrugtreatmentcenters• Currentmethadoneprogram• ResearchfindingsonMethadoneMaintenanceTherapy

• Challengesandwayforward

MyanmardoubleburdenofHeroinandAmphetamine

• LonghistoryofHeroinuseandemergingofamphetamineuse

• PoppycultivationandATSproduction• 1in3PeoplewhoInjectDrug(PWID)islivingwithHIV(48

timeshigherthantheprevalenceinthegeneralpopulation)• 10newHIVinfectionsinthecountry,nearly3occuramong

PeopleWhoInjectDrug• IntegratedBiologicalandBehavioralSurveillance(IBBS)

2017-18estimated93,000PWID

3

SustainableDevelopmentGoals(SDGs)

• Druguse- globalproblem• SDG3 - "Ensurehealthylivesandpromotewell– beingfor

allatallages"• Goal3.5- "Strengthenthepreventionandtreatmentof

substanceabuse,includingnarcoticdrugabuseandharmfuluseofalcohol"

• Indicator3.5.1- "Coverageoftreatmentinterventionsforsubstanceusedisorders"

4

5

6

UNGASS2016ü Recognizedrugdependenceasacomplex,multifactorialhealth

disorder characterizedbyachronicandrelapsingnatureü Encouragethevoluntaryparticipationintreatmentwithinformed

consentü Preventsocialmarginalization andpromotenon-stigmatizing

attitudesü Encouragedruguserstoseektreatmentandcare andfacilitate

accesstotreatmentü Expandcapacityofdrugtreatment

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MajorandMinorDrugTreatmentCenters

OpeningYear #Major DTC #MinorDTC1975 6 222002 20 182014 72019 3 9Total 29 56

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မးယစေဆးစြေရာဂါကသေရးဌာနမား

တငးေဒသႀကး ဌာနႀကး ဌာနငယရနကန ရနကနမႏေလး မႏေလး၊ ေကာကဆည၊

မတလာျပငဥးလြင၊မးကတ၊ပဥးမနား၊ ျမငးျခ

စစကငး မရြာ၊ကေလး ဟမၼလငး၊ ခႏး၊အငးေတာ၊ကသာ၊ဝနးသ၊ပငလညဘး၊ဗနးေမာက၊ေကာလငး၊တမး၊ ေရြဘ၊ေမာလက၊ ထးခင၊ ကန႕ဘလ၊ ကြနးလ၊

ဧရာဝတ ပသမ၊ဟသၤာတပခး ပခး၊ျပည၊ေတာငင သာယာဝတမေကြး မေကြး၊ပခကတနသာရ ျမတ၊ထားဝယ ေကာေသာငး

9

မးယစေဆးစြေရာဂါကသေရးဌာနမားျပညနယ ဌာနႀကး ဌာနငယ

ကခင ျမစႀကးနား၊ ဗနးေမာ ပတာအ၊မးညငး၊မးေကာငး၊ဖါးကန႔၊ ဝငးေမာ၊မးေမာက

ကယား လြ ငေကာကရင ဘားအ ျမဝတခငး ဟားခါးမြန ေမာလျမငရခင စစေတြရမး ေျမာက လားရႈး ေကာကမ၊ကြတခင၊မဆယ၊နမခမး၊မးမတ၊နမဆန၊

မနတ၊မးကး၊ကြနလ၊ပနဆငး၊ေလာကကငရမး ေတာင ေတာငႀကး၊ လြယလင ကေလာ၊ ကြနဟနး၊မငးရႈး၊နန႔ဆန

ရမး ေရ႕ ကငးတ တာခလတ၊ မငးဆတ၊မငးျဖတ၊မငးေယာငး၊မငးယမး10

မးယစေဆးစြေရာဂါကသေရးဌာန အသစမား ၂၀၁၉

တငးေဒသႀကး ဌာနႀကး ဌာနငယရနကန သဃနးကြနးေဆးရမႏေလး မႏေလး၊ ကတင၃၀၀

သငၾကားေရးေဆးရစစကငး ေဖါငးျပင

ဧရာဝတ မအပငကခင မနစ၊ ေရႊက၊ခေဖြရမး ေျမာက သေပါ၊ နမတ၊တန႔ယနး၊ေနာငခ၊သႏၷ

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• MajordrugtreatmentcentersareattachtotheMentalHealthHospitalsandGeneralHospitals– exceptMyitkyina

• Major– Specialist,inpatient(atleast10beds),methadonetreatmentin7majorDTCs

• Minor– outpatient,methadonetreatmentin34minorDTCs

(၁၉၇၄ - ၂၀၁၇) မတပတငလနာဥးေရ ႏင သးစြသညမးယစေဆးအမးအစား

စဥ သးစြသညမးယစေဆးအမးအစား လနာဥးေရ၁။ ဘနးျဖ ၆၀၇၁၆၂။ ဘနးမ ၄၀၃၉၉၃။ စတၾကြရးသြပေဆး ၃၂၀၅၄။ စတျငမေဆး ၃၀၆၅။ ေဆးေျခာက ၇၅၂၆။ အျခား ၅၄၆၂

၂၀၁၈ ခႏစ လနာ အသစ၊ အေဟာငး အေရအတြကàóåÑÉIÑ {=ïÇâáÑX~DçjìaX îäÉãíçéÑlaX~C îäÉãí~xãáÑXlaX~C éâéâ~óÖáÑX

ìÅëáÑ ၃၆၁၄ QTM QMUQ

ééÑìÇâáÑX ONMT OQ ONPN

êbü~îX TQV STP NQOO

CÉÑìâÉÑ QTV QQQ VOP

CpêÑX=E~àêãìÑF TSN NMQ USR

CpêÑX=Eí~CprF ONU O OOM

CpêÑX=E~ïãáÑF U Q NO

ïÉçcãCa NPT P NQM

ógÅäX NPN M NPN

ìCáÑ PRM NQM QVM

êdÉÑ OQR NUS QPN

éâéâ~óÖáÑX UTVV OMRM NMUQV

၂၀၁၈ လနာ အသစ အသကအပငးအျခား

10 362

16651810

2878

1492

514 68

>15 15-19 20-24 25-29 30-39 40-49 50-59 > 60

၂၀၁၈ လနာ အသစ သးစြသညမးယစေဆးအမးအစား

íêëÇhXíéãX CÉÑìâÉÑ êbü~îX ééÑìÇâáÑX ìÅëáÑCpêÑX

Eí~CprF

CpêÑX

E~ïãáÑF

CpêÑX=

E~àêãìÑFógÅäX êdÉÑ ìCáÑ ïÉçcãCa éâéâ~óÖáÑX CãÅÇâáÑbpâÉÑX

ÄÇÉÑXàòi OSP STR OMPT PRNO NMU P TQS PT P M NNS TRMM URKOQ

ÄÇÉÑXêg OV NT OV PP SR Q NP NM M M M OMM OKOT

~èX~àÅãìÑ P Q M M M M N O M M M NM MKNN

éÇïÑàáÇêÑ~èX M M M M M M M M M M M M MKMM

éÇïÑjìd~èX NUP RN QN SV QR N N UO OMS PRM NU NMQT NNKVM

íàÅãX N O M M M M M M PS M P QO MKQU

éâéâ~óÖáÑX QTV TQV ONMT PSNQ ONU U TSN NPN OQR PRM NPT UTVV NMMKMM

၂၀၁၈ လနာ အသစ သးစြသညနညးလမးမား

çâeXédgçåÑÜÉ

åÑXîêÑX

CÉÑìâ

ÉÑ

êbü~

îX

ééÑìÇâ

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F

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F

ógÅäX êdÉÑ ìCáÑïÉçcã

Ca

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X

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ÉÑX

êëÇh={=éãX PN PN OP SO OR P NP R NT M RQ OSQ PKMM

CpiàÅáÑX OPV OQR QOP TMR NMV Q OMQ VS OOQ PRM TU OSTT PMKQO

í~jìãñÇâX OMV QTR NSRP OTRQ UQ N RPQ PM Q M R RTQV SRKPQ

Cpier M M U VP M M NM M M M M NNN NKOS

íàÅãX M M M M M M M M M M M M MKMM

éâéâ~óÖáÑX QTV TQV ONMT PSNQ ONU U TSN NPN OQR PRM NPT UTVVNMMKM

M

METHADONEMAINTENANCETHERAPY

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WHO2016RecommendationsforMMT

• AllindividualswhoaredependentonopioidsshouldbeofferedMMT– Policiesshouldencourageflexible

dosingschedules,includinglevelandduration

– HIV,TBandHBV/HCVtreatmentshouldbeadministeredsimultaneouslywithOST

– OSTfacilitiesshouldalsoinitiateandmaintainARTon-site

19WHOHIVConsolidatedGuidelinesforKP2016(http://apps.who.int/iris/bitstream/10665/246200/1/9789241511124-eng.pdf?ua=1)

WHO2016RecommendationsforMMT• Forpeopledependentonopioids,MMTishighlyeffectivein

improvinghealthoutcomesandreducingcriminalactivities– Reducesinjectingbehaviorsthatputopioid-dependentpeopleatrisk

forHIV– ImprovesretentioninHIVtreatment

• MMTshouldbeprovidedfreeofchargeorcoveredbypublichealth-careinsurance

• Shouldbeaccessibletoallthoseinneed,includingthoseinprisonandotherclosedsettings

• MMTshouldnotbecompulsory;patientsmustgiveinformedconsentfortreatment

20WHOHIVConsolidatedGuidelinesforKP2016

UNDP,WHOandUNAIDS2012:GuidanceforSettingOSTTargets

•HowmanyPWIDshouldbeplaceonOST?–ForeffectiveHIVprevention,400per1000PWID(40%)

–Programsshouldtargetabout40%

21WHO,UNODC,UNAIDS2012(https://www.who.int/iris/bitstream/10665/77969/1/9789241504379_eng.pdf?ua=1)

Evidence:MMTdecreasesinjectionbehavior

22Gowing etal2008OralsubstitutiontherapyofinjectionopioidusersforHIVprevention.CochraneReview

• ComparesinjectiondruguseamongcohortsinandoutofMMT• Riskofinjecting13-55%lessamongthoseinMMT

ForPWIDonARTtreatment,MMTincreasesHIVtreatmentadherence• Non-engagementinMMTisassociatedwithHIVtreatmentdiscontinuationamongHIV-positivedrugusers• ThoseonMMTareat0.58timestheriskofHIVtreatmentdiscontinuationasthosenotonMAT(p<0.001)

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MethadoneMaintenanceTherapy• Startedat3MajorDrugTreatmentCentersin2006withtechnicalassistantbyWHO

• Currently55methadoneclinicsand16,348takingMMT

• TotalcumulativenumberwhoreceivedMMT–39,006

• Scalingup16methadoneclinicsin2019

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NSPIIITargetsonMMTprogram

2018 2019 2020

MMT(currentwholecountryMyanmar) 23316 27658 32000

MMTAchievement 15994

MethadoneclientsinStateandRegionYangonRegion

4%MandalayRegion14%

KachinState45%

ShanState13%

SagaingRegion24%

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ရနကန တငးေဒသႀကး မကသာဒးေဆးခနး - ၂ ခနး လနာ - ၅၉၈ ဦး

ကခငျပညနယ မကသာဒးေဆးခနး - ၁၈ ခနး လနာ - ၇၂၃၅ ဦး

စစကငးတငးေဒသႀကး မကသာဒးေဆးခနး - ၁၅ ခနး လနာ - ၃၈၂၃ ဦး

မႏေလးတငးေဒသႀကး မကသာဒးေဆးခနး - ၄ ခနး လနာ - ၂၁၉၄ ဦး

ရမးျပညနယ မကသာဒးေဆးခနး - ၁၆ ခနး လနာ - ၂၁၄၄ ဦး

PWIDonMethadoneMaintenanceTherapybyStatesandRegions(2015-2018)

- 1,0002,0003,0004,0005,0006,0007,0008,000

Kachin Sagaing Shan Mandalay Yangon

Num

bero

fPWIDonMMT

State/Region

2015

2016

2017

2018

Source:MMTProgrammeReport

MethadoneCoverageSubnational2018

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NumberofMethadone

Clinic

Numberofcurrent

methadoneclient

Numberofnew

methadoneclient

PWIDPopulation

sizeestimate

MMTcoverage

6monthretention

rateHIVpositive HIVtested

YangonRegion 2 598 145 2848 21% 63% 74 397

MandalayRegion 4 2194 422 10095 21.73% 72% 15 339

KachinState 18 7235 3129 21827 33.15% 67% 568 1858

ShanState 16 2144 919 30288 7.08% 59% 89 773

SagaingRegion 15 3823 1757 19064 20.05% 64% 277 1760

RESULT

TrendsofHIVprevalenceamongmostatriskpopulation,HSS2000-2018andClientsonMethadone2006-2018

02000400060008000100001200014000160001800020000220002400026000280003000032000

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2016 2018

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PWID

FSW

#MMT

MSM

ProcurementofMethadone(2011-2019)Year Numberof

bottleUnitprice

USDYearwisetotal

USDFunding

2011 5,718 32.00 182,976 GlobalFund

2012 5,816 30.20 175,643 GlobalFund

2013 10,575 30.20 319,365 GlobalFund

2014 21,811 30.20 658,692 GlobalFund

201525,585 23.60 603,806 GlobalFund

9,125 23.60 215,350 MOHS

2016 37,510 20.50 768,955 GlobalFund

22,400 20.50 459,200 MOHS

2017 54,200 17 921,400 MOHS

2018 32,200 16 515,200 GlobalFund

2019 41,349 16 661,584 GlobalFund

RESEARCH

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1.EFFECTIVENESSOFMETHADONEMAINTENANCETHERAPYINMYANMAR(2018)DDTRU&WHO

34

MMTtreatmentoutcomes:Clientretentioninmethadonetreatment

0%

10%

20%

30%

40%

50%

60%

70%

80%

>=6months >=12months >=18months

KALE(n=363) MUSE(n=283) YANGON(n=641) MYITKINA(n=367)

MONYWA(n=37)

Note:Allclientswhohadcompleted6monthsonMMTormorewereincludedinthisanalysis.Thoseclientstransferredoutwereexcluded.Retentionfor>=18monthsormorenotshownforMonywa duetosmallsample. 35

PredictorsofretentioninMMT

ThesinglemostconsistentpredictorofretentioninMMTinallsiteswas“receivingamethadonemaintenancedoseequalorabove60mg/day”.• Dailymethadonemaintenancedose≥60mgwasapredictorof6

to12monthsandmorethan12monthsretentioninKale,Muse,YangonandMyitkyina;

• DemographicfactorspredictingMMTretentionwerebeing30yearsorolderinKaleandMyitkyina,andbeingmarriedinMuse;

• ThesampleinMonywa (n=37)didnotallowformultivariableanalyses.

36

FactorsdeterminingMMTretention

Variables >=6MMT<12months(reference:MMTdiscontinued)

MMT>=12monthsorcomplete(reference:MMTdiscontinued)

30yearsorolder(ref:<30years)

Kale:OR=2.4 (95%CI:1.2-5.1)*Myitkina:OR=1.1 (95%CI:1.0-1.2)

Kale:OR=2.1(95%CI:1.1-3.9)*Myitkina:OR=1.1 (95%CI:1.0-1.2)

Beingmarried(ref:single)

Muse:OR=3.3(95%CI:1.2-9.1)*

Methadonedose≥60mg/day(ref.<60mg/day)

Kale:OR=3.9 (95%CI:1.8-8.4)*Muse:OR=2.8 (95%CI:1.1-7.8)*Yangon:OR=7.5 (95%CI:4.1-14)*Myitkina:OR=2.8(95%CI:1.1-7.2)

Kale:OR=5.6 (95%CI:2.8-11.2)*Muse:OR=4.3(95%CI:1.8-10.5)*Yangon:OR=9.0 (95%CI:5.3-15.0)*Myitkina:OR=6.0 (95%CI:1.9-18.5)

Heroin(ref.opium) Non-significant Non-significant

Injection(ref.non-injection) Non-significant Non-significant

Morethandailyuse(ref.lessthandaily)

Non-significant Non-significant

Note:CI=ConfidenceInterval.*Regressioncoefficientp-value≤0.05.Multivariablemultinomialregressionmodelsadjustedforvariablessignificantatp<0.200inunivariateanalysis.Variablesadjustedforwereage,drugtype,frequencyofuse,administrationroute,MMTdoseandHIVtestinginKale(n=363);age,maritalstatus,treatmentoptionandMMTdoseinMuse(n=283);age,methadonemaintenancedose,HIVtestandHBVvaccinationinYangon(n=641)andagemethadonemaintenancedose,sharedneedlesandsyringesanddurationofdruguseinMyitkina (n=367).UnivariateanalysesonlyweredoneforMonywa duetothesmallsample(n=37).ThereferencegroupisthosewhodiscontinuedMMT.

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DiscussionØ AdaptMMTservicestoclientcharacteristics ineachsite(eg.youngMMT

clients);roleoffunctionalsupport(forMMTclientswhoaresingle).Ø GoodretentioninMMTatmaintenancedose≥60mg/day;Explorereasonsfor

lowdosesandsolutionstodeliverthem.Ø MMTconstitutesagoodentrypointfordruguserstoaccesspreventionand

treatmentforHIVandhepatitisBandhepatitisC.Ø ExpandavailabilityofHIV,hepatitisBandCtestingservicesandtestkitsinMMT

sites;Ø Waysofreflectingreferralsinone-stopsitestotrackprogress?Ø Challengeofmeasuringchangeindruguseandriskbehavioursovertime;

follow-updatacouldbecollectedat3/6months.

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2.HARMREDUCTIONSERVICEAVAILABILITYANDLINKAGEFORPWIDSAMONGPUBLICANDPRIVATESERVICEPROVIDERS(2018)

39

• IRprojectID– 46• FundedbyMinistryofHealthandSports• Dateofreceivinggrant- 1September2017• Estimateddateforfinalreporting- 31March2018

40

Findings• usingdifferentidentificationclientcodes• lackoffulltimemedicalofficerinmethadoneclinic• takehomemethadonepracticeneedtofollowtheguideline

• clientassessment andurineanalysis– notregularbasic• dropout/defaultertracingcouldnotbedone• MisperceptionsofcommunitytowardMMT,harmreductionservices,particularlyneedlesyringeprogram

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RECOMMENDATIONS• Patientuniqueidentifiersystemshouldbeestablishedfor

properandvalidrecordingofdrugusersandstrategicplanning

• MMTexpansionisrecommendedconsideringoperationalfactors

• HumanresourceproblematMMTclinics,posingbarrierforeffectiveserviceprovisionshouldbesolvedurgently

• CommunityawarenessraisingonMMTservicesshouldbeorganized

42

RECOMMENDATIONS(cont;)• Self-helpgroupsshouldbestrengthenedinvolvingallNGOs

andMMTprogramme forrecoveryfromsubstanceusedisorderandtoadvocatethecommunity

• FuturestudyoncommunityacceptanceandlookingatHRserviceaccessibilityandbarriersfromclientperspective

• RecommendedtodevelopthenationalguidelineofharmreductionforPWIDsforstandardizationofserviceprovisionandreferralamongserviceproviders

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3.HIV,HEPATITISBANDHEPATITISCANDRETENTIONINCAREAMONGSTPEOPLEWHOINJECTDRUGSANDAREPLACEDONMETHADONEMAINTENANCETHERAPY,YANGON,MYANMAR

0.2

.4.6

.81

Prop

ortion

retai

ned

0 .5 1 1.5 2 2.5 3Years

630 421 295 197 108 49 0 Number at risk

95% CI Survivor function

Kaplan-Meier survival estimate

Kaplan-Meier plot showing retention rates (and their 95% confidence intervals) amongst PWID enrolled for MMT in Yangon, Myanmar: 2015 to 2017

Retentionat3yrs46% (41-52%)

Retentionat6mnths76%(72-79%)

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CHALLENGESANDWAYFORWARD

46

Challenges• TreatmentGap– somedrugtreatmentcentersarenotfullfunction,

emergingtrendofstimulantdruguse,LowCoverageofMMT<20%• Notenoughhumanresourcefordrugtreatmentworkforce• Relapse/Dropoutrelatedmainlytotransportationand

unemployment• Psycho-socialsupportcomplimentarytotheholisticcareand

treatment• M&Esystemformethadoneprogram• Stigmaanddiscrimination

47

WayForward• DeveloptheNationalStrategicPlanforNationalDrugControlPolicy

• DevelopmentofMentalHealthPolicy• ReviseandpublishtheMethadoneGuideline3rdEdition

• ProcurementofMethadonefromDomesticmanufacturebyBPI,MinistryofIndustry

• DeveloptheguidelineandSOPfordrugtreatmentcenters

48

WayForward(cont:)• OverdosepreventionandNaloxonedistribution• Telementoringprogramamongdrugtreatmentcenters• Operationalresearch– femalePWID,communityacceptance,clientperspective,changeindrugtypeofuse,riskbehavior andcosteffectivenessstudy

• Scalingupthemethadoneclinicsconsideringoperationalfactors

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Conclusion• Substanceabuseinruralandurbanareasisamajorpublichealthconcern.

• Preventionisstillveryimportantandshouldbehighlighted.

• Addictionisadiseaseandshouldbefocusedonbiopsychosocialandbehaviorchangeaswell.

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THANKYOUVERYMUCH

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