Harm Reduction and treatment for opium addict in hill tribes of Northern Thailand
Princess Mother National Institute on Drug Abuse Treatment

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Drug abuse is a world problem that has become a priority in all countries. In Thailand, the opium cultivation problem has been greatly diminished in the form of opium crop substitution and expanding the development of covered infrastructure in order to improve the livings of hill tribes in agriculture, public health and education altogether since 1969 that the areas of opium cultivation had been decreased from 112,000 rai to 744 rai in 2004 . From the monitoring survey, it was found that illegal opium cultivation had been increased to 1,319 rai in 2010–2013 that the recurred opium cultivation had been discovered in three Northern provinces in 7districts which were Chaiprakarn, Chiang Dao, Mae Taeng, Wiang Haeng and Omkoi in Chiang Mai Province and Pai, Mae Hong Son and Mae Ramat in Tak Province. The survey target is covered 126 villages in 11 sub districts, and the target population is 5,493 households (26,707 people). Moreover, the border which was adjacent to the source of drug production and difficult to access resulted in the number of opium addicts that cannot be observed in the real number. The Northern Substance Abuse Center estimated the number of opium addicts in Omkoi District in 2012 by interviewing the villagers and health officials, it was found that there were 15-20 opium addicts per village which were about 4,500 people or 8% of all district population (57,951 people) that can be divided into 3 groups which were; 1) the elderly accounted for approximately 35% (1,575 people), 2) working age group accounted for 30% (1,350 people) and 3) teenagers accounted for 35% (1,575 people). The opium addicts changed the use of opium from smoking to injection method. In the treatment of substance abuse people in Tha Song Yang District in 2010 – 2012, it was found that 93.75%, 100% and 89.29% of the people who received the treatment were opium substance abuse person that 26.67%, 39.62% and 24.89% respectively were the people who applied injection. According to the study of medical records of Thasongyang Hospital in 2013-2016, it was discovered that there were 125 opium addicts who used injection method. It was also found that 1.6 percent of them infected with Hepatitis B, 76.8 percent infected with Hepatitis C and 0.8 percent of them infected with HIV. In the group of Hepatitis infected people, it was found that 32.7% of them had abnormal liver enzyme value. Furthermore, 1.6% and 1.7% of them had liver cirrhosis in 2015-2016 related with the information from Mae Ramat Hospital in Tak Province which was found that opium addicts who injected that 12.8% of them infected with Hepatitis B whereas 82.1 % and 7.7% of them infected with Hepatitis C and HIV respectively. The communities in the highlands of the Northern part are remote areas that most of travelling between villages is inconvenient and also discovered that the scare of infrastructure and electricity. Moreover, it was also discovered that the scarcity of infrastructure and inconvenient transportation were the problems found in highland areas.

B. Strategic Approach

 2. What was the solution?
For the past 30 years, the institution provided treatment by detoxification; however, relapse method (90%) had also been used. The initiative of the treatment of the opium addicts applying Harm Reduction in the operations in order to provide patient-centered flexible treatment to help them quit using opium and have better improved quality of life. The community participation is very important that the patients can access to receive quality services.

 3. How did the initiative solve the problem and improve people’s lives?
In the past, the policy of drug war had been focused on suppression, arrest and imprisonment of drug users. The drug users had been seen as the offender and criminal who create social problems rather than the patients who need treatment. The treatment of the opium addicted patients would be treated by detoxification method with tincture opium or methadone in order to obtain abstinence. However, the treatment in the past showed that there was high rate of relapse, and the patients dropped out of treatment system. The principle of harm reduction and humanize has been applied in the new concept that a drug user is just a human who needs to be treated as a patient with chronic brain disease so the therapists and people should have new perspective attitude that the drug users are patients who need continuous treatment as same as other chronic disease patients. In addition, opium users are chronic opium users who cannot stop using opium easily so harm reduction measure has to be applied in order to decrease negative impacts resulted from drug abuse and protect harm while they are still using opium rather than stop using it immediately especially those who use drug injection by sharing needles together resulted in the spread of infectious HIV, Hepatitis B and C. There are 10 service sets of harm reduction composed of Information Education and Communication, Methadone maintenance treatment, Needle syringe program, Condom, Voluntary Counseling and testing, Sexually transmitted disease, Tubercle bacillus investigation, Peer Educator, Counseling for Harm Reduction, Rehabilitation therapy including with social activities to help the patients access into public health service system which provides holistic and all-sided cares for the patients in order to decrease infection, reduce complications from opium addiction and improve their quality of life consisted of methadone maintenance treatment (MMT) which is an important set of service in the therapy of those addicted to opium and heroin. The adequate level of methadone will be alternative taken in order to help the patients not to suffer from lack of drugs. The harm reduction service is continuous long-term care together with all-sided health service which will reduce dangers of drug use, and it is accepted as effective, safe and worth service in international level for both patients and service providers. Moreover, it can reduce the number of illegal drug users, the expenses of the patients and their families and mortality rate. The existence can also be increased in the treatment system. Apart from those mentioned above, the form of treatment is an integrated proactive service system with the participation of all sectors that has never been done before. This new concept of treatment can be accessed by opium addicts that they have problems with many complex dimensions, for example, living in the remote areas, lack of access to government services both in education and public health and lack of career opportunity, etc. Furthermore, after receiving methadone maintenance treatment (MMT), they are also eligible for health care under equal human rights that they will not return to use the opium, and they can work and sustain themselves in order to improve good quality of life.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The conventional therapy is hospital base by using Methadone Detoxification. Most of opium addicts are forced into the treatment to receive total abstinence. This resulted in higher rate of relapse, and the rate of access into treatment and the retention rate are decreased. For this reason, Harm Reduction applied by establishing Drop-in Center to provide medical services and convenient travelling for the community. Moreover, all sectors in the civil society, there is a process of searching and accessing into the treatment voluntarily. The MMT must be applied in high dose which is enough to prevent craving until the patients receive total abstinence, and other health services are also provided together with occupational support for the families and community participation in caring. As a result, more patients will access into the services that the compliance and the retention rate will be increased. Moreover, the patients will be healthier, and the stigma will be decreased In many countries, Harm Reduction is implemented by NGO which emphasized MMT and needle exchange. This new innovation has been implemented by the government and community involvement in order to provide continuity and sustainability that focused on standard health services which are covered and provided equally.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The expansion of the royal project for sustainable problem-solving of the opium cultivation areas had implemented in the first phase (from 2010-2013) by determining strategies which were 1) career development, 2) the strengthening of community and social development and 3) development of the community to solve opium problems. When the half-plan was evaluated, it was found that the strategy 3 (development of the community to solve opium problem) cannot bring the opium addicts in 7 target communities to access to treatment and rehabilitation and develop quality of life as defined in the strategy due to the lack of a main institution for drug abuse treatment that the patients were not treated appropriately. The Ministry of Public Health had begun to play a role in determining the framework of solutions, and assigning the Princess Mother National Institute on Drug Abuse Treatment (PMNIDAT) as the main organization to develop treatment program. The PMNIDAT has participated in the project since 2012 that its objective is to provide standard and quality treatment to the opium addicted patients thoroughly, fairly and equally and covered all target groups by applying the concept of harm reduction and process of community participation in the development. In addition, a Drop-in Center was established to provide long-term methadone and healthcare services that emphasized on patients’ convenience to access to the services which resulted in good quality of life. The institution was responsible as a mentor to coach the treatment team to rely on themselves in the implementation. After that, the institution team would be withdrawn and become supervisor to monitor the operation results continuously.
 6. How was the strategy implemented and what resources were mobilized?
The implementation of the master plan consisted of two phases; phase 1 (2012-2013) and phase 2 (2014-2015) that requires strategic planning and management of limited time and resources in order to achieve maximum benefits from the covered operations and driving mechanism to achieve goals. In the first phase 1. All levels of staff had been developed to perceive and understand the effective treatment for opium addicted patients with harm reduction principles. 2. Adjusting the attitudes and viewpoints of the therapists, law enforcement agencies, community leaders, civil society officers and stakeholders to be positive with the help and treatment of the opium users, that they are chronic patients not criminals. 3. Creating engagement by organizing workshops for health officials, government officials, police, community leaders and village health volunteers that they participated to think, analyze, determine the target and plan the implementation together which focused on building sustainable care for the opium addicts in the community according with each area context. 4. Developing the treatment process of opium addicts in the community in the form of interdisciplinary that the community was involved in all aspects not only the responsibility of public health agencies unilaterally. 5. Managing budget disbursement to be streamlined in operation. 6. Providing suggestion and coaching system that the district health promoting hospital would implement the operation in each area closely and help solving problems creatively and friendly all the time. 7. Organizing seminars for working staff in all areas in order to evaluate and modify the operation together. In phase 2 1. Establishing “Drop-in” centers in hospitals, sub-district hospitals and sub-district administration organizations. The selected place of establishment was focused on the convenience and saving for travelling to receive health services that the patients will trust and feel comfortable with the services. 2. Focusing on the sustainability and encouraging the opium addiction treatment into normal system of public health service in the area. 3. Strengthening family and community including with stopping opium abuse and creating better quality of life. 4. Developing academic matter as the knowledge base coupled with working in order to receive the form of treatment of the opium addicts in highlands matched with the way of life of hill tribes that resulted in better development of life quality. The Budget Management The main budget has been supported by the Department of Medical Services, Ministry of Public Health which was used in the project management, human resource development, the treatment of opium addicts in the community (Drop in) with Harm Reduction concept and research studies. The National Health Security Office (NHSO) has supported the project with the reimbursement of MMT service charges (35 baht/ person/day) for the hospital. The local government organizations have supported by bringing the patients to the treatment system and following-up patient care in the community. The Highland Research and Development Institute (Public Organization) has supported by providing help to the patients in order to have the opportunity to develop agricultural profession that they can access to the market, and they have been employed.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The project based on community and cooperation consisted of many involved agencies as the stakeholders in designing activities and co-operation in the treatment of opium addicts as follows. 7.1 The Princess Mother National Institute on Drug Abuse Treatment (PMNIDAT) was mainly responsible for project implementation of all areas and driving the policy to provide methadone medication into health services of the community, for example, coordinating with the Food and Drug Administration in order to increase the dispensation of methadone in community hospitals and taking care of the prerogative of methadone maintenance treatment in the concession of the National Health Security Office (NHSO). 7.2. The regional Thanyarak hospitals were responsible for managing, monitoring, supervising, following up the operations in the areas of responsibility to matched with the objectives and reporting the progress to the PMNIDAT (Thanyarak Chaing Mai Hospital was responsible for 5 districts in Chang Mai Province whereas Thanyarak Mae Hongson Hospital was responsible for the areas in Pai District, Mae Hong Son Province). 7.3. Provincial Public Health Offices in Chaing Mai, Mae Hong Son and Tak were responsible for managing and facilitating the operations in the target areas in each province together with staff support. 7.4. Community hospitals/ district health promoting hospitals were responsible for the implementation of treatment services for the opium addicts in the areas and integrated coordinating with the involved organizations to help the opium addicted patients. 7.5. Community Sector such as local government, village chief, headman, community leader and NGO was responsible for communication, searching, forwarding and follow up action. 7.6. Security officers were responsible for providing security. 7.7.The Highland Research and Development Institute (Public Organization) was responsible for supporting and encouraging agriculture profession for the patients.

 8. What were the most successful outputs and why was the initiative effective?
According to the operation results in 4 years, it was found that the spread of HIV and Hepatitis B and C had been reduced among opium addicted people in 7 districts in Highland regions that they received important harm reduction services which wereMethadone maintenance treatment, Voluntary Counseling and HIV Testing including Detection of Tubercle bacillus and Hepatitis B and C. The achievement of the project: 1) The opium addicts had participated in the treatment service system from 2012-2013 (735 people) ,and there were 816 people in 2014-2015. The project result showed that the patients accepted the treatment and that 92.89% of them still received treatment. 2) There were 14 Drop–in centers of harm reduction that provide methadone medication and 10 service sets of covered health services which help the patients to receive medication and services conveniently and safely. These were the new pattern of services that never been appeared before in the areas. 3) The working network of seven districts consisted of physicians, nurses, public health officers, government administrations officers, security forces, the Office of the Narcotics Control Board, the network of community leaders and civil society. 4) The involved personnel in seven districts have been developed for harm reduction and changed attitudes towards the treatment of opium addicted patients in all areas (140 people per year in 2012-2015; a total of 560 people). 5) The Best Practice was received as the centers of harm reduction from drug abuse in communities. These centers were the place to study visit and exchange knowledge between Thai and overseas drug abuse treatment agencies such as Santivana health promoting hospital in Chaiprakarn District, Ban Ton Lung health promoting hospital in Maetaeng District and Ban Kamwan health promoting hospital in Maeramat District, etc. that they were chosen to present their works in various academic fields. The project implementation results can make proud of working teams in all areas That they can help the opium addicts in highlands to reveal themselves and access to the treatment services. Furthermore, the patients also reduced and quitted opium addiction when they were ready. These resulted in better quality of life and peaceful society. The staff also had joyfulness to face with difficult and challenging works that they worked with philanthropic spirit to help fellowmen to be delivered from suffering.

 9. What were the main obstacles encountered and how were they overcome?
In the implementation, there were found problems and solutions described as follows. 1. The remote areas were inhospitable regions and difficult to access. The transportation was inconvenient due to the rainy season that the areas could not be accessible for the operations. Therefore, the process of studying, planning, reviewing and planning was created to access to the areas according to climate conditions and plan to schedule appointments with the patients in advance. 2. The communication was difficult due to various hill tribes and highland areas which was the obstacle in treatment. Thus, the solution is to requesting helps from the tribesmen (officers and patients) who know the languages as interpreter to communicate. 3. The opium was the remuneration for mercenary career, and opium cultivation was for family consumption or sales so opium addiction is highly expanded that it was difficult to implement treatment. Therefore, the building of motivation to access in the treatment was achieved by encouraging family participation and developing family members to become volunteers to help and take care of the patients. 4. The target areas were not ready for the operation to prevent and resolve drug problems, and they are also risk areas for the staff. For this reason, the plan was changed by selecting the areas which were safe to access and ready to develop first. 5. The attitudes and perspectives of the therapist and the relevant person that the opium addicts must quit from the addiction decisively was contradicted to the tribal cultures and tradition. Therefore, the adjustment of the attitudes toward the patients that they suffered from drug addiction brain disease and needed treatment must be created.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The benefits from the implementation can be divided as follows. The operations of treatment of opium addicts in highland areas resulted in the maintaining of 758 people or 92.89% of all patients (816 people) in the treatment and follow-up process. Moreover, 147 people (18.01%) can quit from opium addiction, and the rest of 661 people (80.60%) still receive methadone medication continuously. The Harm Reduction concept can be applied in the treatment operations of opium addicts in highlands that they can stop using from by receiving treatment services. This resulted in better quality of life that they can work and earn money for their families as shown in the sample case below. Sample case: Thai male, 48 years old, avocado farmer Background: He used to take amphetamines about ten years ago in order to stay in active work (avocado plantation area of 30 rai), then he changed to use opium 6 years ago due to reducing pain from gardening work. He used to stop using drugs by himself 5-6 times but it was not successful because he cannot tolerate with drug withdrawal symptoms so he decided to treat at the clinic 4-5 times. However, he could not stop using drug. Until this project had been accessed in the area in July 2014 at Santivana health promoting hospital, he was treated by receiving methadone maintenance treatment continuously with equity and impressive services. Then he has accepted and revealed himself as a member of drop in center at Ban Santivana since September 2015. Professional/ Income: The 30 rai of avocado garden was run by himself. He used to attend the Royal Agricultural Station Angkhang, however, he could not operate under the project because he was addicted to opium which affected his family so that that his children left the house to work in Bangkok so he had to work hard and increase using amphetamine and opium. The income was not inconsistent because the avocado trees were not growing completely, and the production was ineffective. After receiving Methadone Maintenance Treatment (MMT) and harm reduction services in 10 10 service sets of harm reduction, he had better health and mental state, and the family problems were also reduced. (His wife came to participate in the center’s activities so she could understand about the treatment and receive correct information from the physicians and staff.) Moreover, 5-6 months after the therapy, he was stronger enough to get back to work, and he was supported by the Royal Project Huaypongpattana to improve soil quality which resulted in more effective production that the income was increased. At the present, he can expand avocado garden to 70 rai. The income from avocado export is about 1.2 million baht, and he also invites his neighbors to enter into partnership with him in avocado export.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Drug addicts are grouped as patients with chronic brain disease that they not only have physical illness but also complex problems in physical, mental, emotional, social and economic issues which needed to be treated. In the initiative, the patients would be respected in their rights and human dignity, and the treatment of human as individual was recognized by focusing on natural of drug addicts as flexible treatment base resulted in equal practices. Furthermore, the patients would be accepted, more confident and have opportunities to have standing areas in the society. For this reason, they realized to change their behaviors and became good person in the country. Thus, the organization would have implemented to drive the furtherance of the policy as follows. 1. Meeting and Planning with the involved agencies such as the National Health Security Office (NHSO) and the Food and Drug Administration to push the policy in order to make the methadone maintenance treatment issue as the main measure in the treatment of heroin and opium addicted patients especially with those who used injection method. 2. Preparation for the treatment standard with long-term methadone medication in Thailand by the network of service providers, experts and partners of the network of civil society that supported in academic aspect by WHO ,UNAIDS , UNODC and Dr. Nick Walsh (Consultant MMT WHO) and organizing seminars/ workshops for all methadone clinics in the country. 3. Encouraging the policies into practices in the standard operations of long-term methadone treatment in Thailand by sending cooperation request document to the Ministry of Public Health which signed by the permanent secretary (Appendix 3) As a result, the service providers in drug hospitals and clinics nationwide have developed and provided long-term methadone treatment and harm reduction service to the opium and heroin addicted patients according to the standard with friendly service. The service was responded to the right of the patients completely in accordance with the intention of the Ministry of Public Health which focused on the policy development in order to provide equal medical practices, and the service can be accessed thoroughly and extensively. Furthermore, it is also guaranteed that the patients must receive quality and good standard services. However, the supervision of the hospital clinical drug across the country has been continued.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The families which consisted of opium addicts have financial problem, family violence and controversy. They are social stigma and discriminated from community opportunities, for example, the financial support from the government is not provided to these families so the children are uneducated because they have to work to earn money for livings and help their family. When opium addicts participate and remain in the treatment, they will have better health including with the recognition from the community to continue their career that they will have enough income for living and saving. The family problems will be decreased, and acts of violence on women and children will be reduced. As a result, the women/wives will have better quality of life that they will not have to work hard and responsible for nurture the family. Furthermore, the women will have better physical and mental health that the problems raised from drug abuse of their husbands are eliminated so they can do parental duties more. The children will receive love, care and warmth from their parents resulted in appropriate development and good education that they will grow up as good citizen to develop their country in the future.

Contact Information

Institution Name:   Princess Mother National Institute on Drug Abuse Treatment
Institution Type:   Government Department  
Contact Person:   VIROJ VERACHAI
Title:   Director of PMNIDAT  
Telephone/ Fax:   +(66) 2 531 0080 ext.528
Institution's / Project's Website:  
E-mail:   aung3030@hotmail.com  
Address:   60 Phahonyothin Road
Postal Code:   12130
City:   Thanyaburi
State/Province:   Phathumthani

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