kanna hayashi lianping ti karyn kaplan paisan suwannawong will small julio montaner evan wood

Experiences with Compulsory Drug Detention in Thailand: Evidence from the Mitsampan

Community Research Project

Kanna HayashiLianping Ti

Karyn KaplanPaisan Suwannawong

Will SmallJulio Montaner

Evan WoodThomas Kerr

HIV Epidemic among Thai IDU

Thai Drug Policy

War on drugs in 20032,800 extrajudicial killings

50,000+ people into drug detention centres

`Thai Drug Policy

The Narcotic Addiction Rehabilitation Act B.E. 2545• Reclassified people who use drugs as “patients” not

“criminals”

• “A rehabilitation centre shall be an institution for treatment under the Penal Code…and a unit of the Department of Probation, Ministry of Justice”

• There are now >85 drug detention centres in Thailand

• Programming based largely on military and physical exercises, religious activities, therapeutic community work

• Near total lack of evidence-based addiction treatment

Thai Drug Policy

Five Fences strategy in 2009-2010300,000 drug users into drug treatment

Photo from the Office of the Narcotics Control Board, Thailand, website: http://en.oncb.go.th/document/e1-act-D-Day2009-1.asp

Kingdom's Unity for Victory over Drugs strategy in 2011400,000 drug users into drug treatment

Photo from : Mahitthirook, A., Laohong, K.-O., 2012. Phones, CDs seized at prison. Bangkok Post, May 18.

Mitsampan Community Research Project• A collaborative research effort involving:

• Serial cross-sectional mix-methods study

• 32 former/active drug users trained as peer researchers

• Peer researchers involved inall stages of the project

Thai AIDS Treatment Action GroupMitsampan Harm Reduction Center

ChulalongkornUniversity

Summer 2008, Bangkok, Thailand

• Three surveys completed by 700+ IDU in Bangkok (2008, 2009 & 2011)

Recruitment through peer-based outreach and word-of-mouth

Peer-administered interviews at the drop-in centres

• In-depth qualitative interviews

Project Design

• 48% of IDU reported having had drugs planted on them by police

9Hayashi, BMC Public Health, 2013

38% reported being beaten by police

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Violence & Neglect in Compulsory Drug Detention

They did not provide any therapy…they just brought us into an environment that was like torture. As soon as they arrived, they just shoved us and kicked us behind bars, and then left us there without doing anything…I suffered withdrawal symptoms…I couldn’t sleep, couldn’t eat and threw up whatever I ate.

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Violence & Neglect in Compulsory Drug Detention

I told them I was HIV positive and had a doctor’s letter…They just didn’t listen. They didn’t try to contact my relatives even though they knew I was sick. I needed medicine and had to see a doctor…Yet they just didn’t care.

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• 96% of those who had been compulsory detention had injected in the past week

• No differences in intensity of drug use were found between those who had and had not been in compulsory detention (p < 0.05)

And does having been in the camp affect the way you use drugs?

I think it hasn’t had any impact on me. It doesn’t affect me. Actually, I think for the younger people…they could use even more heavily…I used to be like that too. I was in prison for a long time…When I got out, I just released that pressure through a big hit. Things can go so wrong. People can just turn to do bad things...Just go extreme. It’s a way to push back.

Impacts of Compulsory Detention on Drug Use

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25% of participants report avoiding healthcare

Kerr et al, IJDP, 2013

COMPULSORY DRUG DETENTION AND INJECTION DRUG USE CESSATION AND RELAPSE

IN BANGKOK, THAILAND

Nadia FairbairnKanna Hayashi

Lianping TiKaryn Kaplan

Paisan SuwannawongEvan Wood Thomas Kerr

RESULTS

• 209 (49.5%) individuals stopped injecting for greater than one year

• 92 (21.7%) individuals stopped injecting between 3 and 12 months.

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Model 1 – Cessation of >1 year

• Incarceration (AOR = 13.07, 95%CI = 6.64 – 25.72) • Voluntary drug treatment enrollment (AOR = 2.75,

95%CI = 1.30 – 5.83)• Number of years since first injection (AOR = 1.07, 95%

CI: 1.03 – 1.11)• Midazolam injection (AOR = 2.48, 95%CI = 1.23 – 4.98) • Older age (AOR = 0.42, 95% CI: 0.21 – 0.83).

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Model 2 – Cessation of 3-12 months

• Incarceration (AOR = 5.47, 95%CI: 2.65 – 11.32)• Compulsory drug detention exposure (AOR = 2.61,

95%CI = 1.18 – 5.80) • Midazolam injection (AOR = 3.80; 95%CI: 1.55 – 9.33)• Voluntary drug treatment enrollment (AOR = 2.83,

95%CI = 1.25 – 6.39)• Methadone treatment exposure (AOR = 0.38; 95%CI:

0.17 – 0.86).

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RESULTS

Self-reported reasons for injection cessation:

•becoming incarcerated (74.0%)•feeling the need to “take a break” from drug use (60.7%)•entering voluntary drug treatment (13.0%)•being sent to compulsory drug detention (10.1%)•hospitalization (9.5%).

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RESULTS

Self-reported reasons for relapse into injecting:

• released from prison/compulsory detention (66.3%)• feelings of boredom (59.4%)• being exposed to triggers (55.2%)• having some money (54.4%)• feelings of depression (40.8%)• personal problems or family issues (19.9%).

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SUMMARY & INTERPRETATION•50% of participants stopped injecting for > year and this was associated with incarceration, which likely reflects lengthy sentences for drug offences in this setting

•Compulsory drug detention was associated with short-but not long-term cessation, as well as relapse, which likely reflects the fact that compulsory detention consists of a 45-day assessment and 4 months of detention

•Voluntary addiction treatment appears to promoting cessation of injecting, while methadone treatment is not, which is likely due to the well-described deficiencies in Thailand’s methadone program

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CONCLUSION & IMPLICATIONS

• Thailand’s compulsory detention system appears to have failed to meet its basic objectives

• Compulsory drug detention is associated with various forms of police misconduct and violence, elevated HIV risk behaviour, interruptions in HIV treatment, and relapse into injecting

• This system interacts with access to care by perpetuating stigma, shame and avoidance of healthcare

• The system of compulsory drug detention should be replaced with evidence-based harm reduction and addiction treatment programs

ACKNOWLEDGEMENTS

• The people who use drugs who participated in and supported the research

• Our community and NGO partners, including the staff of Mitsampan Center and Ozone House staff

• The research staff at the BC Centre for Excellence in HIV/AIDS

• Research team: Kanna Hayashi, Mint Ti, Karyn Kaplan Paisan Suwwanawong, Evan Wood, Nadia Fairbairn, the Peer Researchers Team & co-investigators

• Our funders: Open Society Foundation, Michael Smith Foundation for Health Research

Further informationhttp://uhri.cfenet.ubc.ca/http://www.ttag.info/