content · 2018. 8. 16. · drug addiction is a complex ... •repeatedly incarcerated •polydrug...
TRANSCRIPT
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