Questions/Answers

In the year 2000, Thai drugs situations changed from heroin to methamphetamine, which is easier to find, cheaper and chemically attractive to users, its popularity when compared to previous heroin. Thailand encountered more serious drug problems, the rapid spread of drugs, the lack of well-structured outpatient treatment program and the importance was they have no medication treatment yet. The result of the improvised program is mostly unsatisfied, we found a lot of relapse after the treatment completed (around 95%). The only way is to motivate all patients for entering longterm hospitalization. It has made a client who needs hospitalization cannot enter the inpatient treatment facilities (98% cannot access inpatient). At that time, the increasing in crime rate, violence, overcrowding of inmate and harm-associated events to oneself and others. All made the bad traumatic scene among society. the government is needed to find the best solution to deal with those problems under limited resources. Core group consist of 14 agents under the direction of Ministry of Public health, department of medical services in term of the Princess’s Mother National institute of drugs abuse treatment and rehabilitation (PMNIDAT), an alliance from Bangkok metropolitan, military, narcotics control board and university professor have made a decision to find some OPD program from the Matrix’s Institute, UCLA. Who’s developing the program to deal with a patient who is not ready to enter a longterm rehabilitation. The core group learned this outpatient intervention and tried to adopt all original spirits of the Matrix to Thai context, incongruently styles, so they decided to modify some sessions but keeping the core. There are two main reasons for program development over the decade 1) to increase the accessibility of patients, equity 2) to enhance the efficacy of treatment (reduce dropout, cost, time and increase the quality of life).

This treatment uses behavior and thought therapy techniques, developed according to the Thai context and patient-centered. This is considered to be a concrete innovation in having repeatable activities. This type of treatment has never been done before within ASEAN. Thai government saw the beneficial outcomes towards the addicts, it was then set as the nation's policy to make a quality, easy access, and quick. It's also cost-effective via the support from the state with the approval of quality accreditation under the Public health authorization. All this is to monitor treatment standards to produce the most benefits for the patient.

This report is following goal number 3. This is to create a guarantee for the citizens to have quality lives and well-being. For indicator 3.5.1 regarding the treatment coverage (by medication, psychology, and rehabilitation, along with follow-up treatments for users), with the treatment being outpatients-is to promote the treatment of being patient-centered. This is to make all patients to have easy access to government services. The treatment is quick and cost-and-time-effective. There's assistance in consultations for individuals, groups, and their families. Therapy activities are also suitable and by the patients' ways of living. It's the one standard that's considered very acceptable in helping patients to stop having relapses-percentage wise is 80 (from 2002 to the present). This is the result of having a systematic and constant follow-up procedure with the families and the community (1 year after receiving the treatment).

This treatment makes patients stop using drugs and living lives in accordance with the environment and their responsibilities. They're able to work without causing any family problems ( incoming loss from staying in the hospital). After they're able to stop using drugs, physical and mental health is better too. These results are good for the families, community, and the nation. It also helps decrease the treatment cost and decrease the criminal. When compared with the Matrix Institute, it was found that the achieved results were relatively the same as 80 percent were able to stop using drugs in a year.

Treating outpatients by behavior and thought therapy influences the effectiveness of the treatment by reducing the addiction rate and adding access for the patients. This type of model is available in all community hospitals throughout Thailand, making it all easy for the patients to get the treatment from their areas. The budget from the government helps save the patient’s medical expenses. And also treatment can help the government save its budget when evaluated. With inpatient treatment, the government has to support about 10,000 to 25,000 baht per patient. As for outpatient treatment, the government supports only 3,500 baht per patient. With this, it can help reduce the budget 2 to 8 times for the cost of treating one patient. Moreover, with outpatient treatment, the bed occupancy rate can be reduced-making this group of patients to have more freedom in leading their normal lives in the community. This way, the patients learn how to change their behaviors by living with their own families and communities in real-life situations. The patients can take care of themselves sustainably thereafter, with and equity that's no one left behind.

Even if female patients only make up about 3-4% from the entire patients, their wife- and-mother roles make it difficult for them to get the treatment with inpatient program/treatment. It was found that the number of female patients who were able to get the treatment increased. From the year 2014, the number of female patients who were able to get the treatment was 15,292. The number rose to 21,239 in the year 2019 (38.9% increase). This helped to decrease the stigma of female patients and to support their roles in being the wife and the mother more completely.

The target group is the users of all types of drugs. The treatment program is divided according to the severity of drug addiction. Ministry of Public Health has the policy to sort out the groups called "screening and referring drug addicts". According to the severity of drug usage, the addicts were divided into 3 groups: 1) user group, 2) abuser group, and 3) addicted group. From the statistics going back 5 years (2014-2018), it was found that with inpatients admitting to a voluntary treatment program, the number of patients was 502,396 throughout the country. With the treatment results, it was found that groups 1 and 2 were able to stop using drugs at about 80 % when compared with the treatment of Matrix Institute USA. Saving on expenses was about 10,000 baht per patient. Also, the patients were 85% satisfied with the treatment. They were able to live their lives with own families and the community with ease. Their quality of life (in all fields) was 68%.

With the development of an outpatient program, the team got the idea from Matrix Program, Matrix Institute, UCLA, USA. In 2000, Thailand had set up committee members from 14 departments throughout the country to find an outpatient program. The program was designed by blending both individual and group treatments altogether. Combined with bringing in families and community to learn about drugs addiction process, quitting drugs/abstinence from drugs, living among the patients-all this as being a part of the treatment. This is to influence the knowledge and understanding, to change the outlook and views positively, leading to the change in behaviors of the patients to decrease and ultimately stop using drugs sustainably. For the first two years (2000-2001), the team was able to transfer the knowledge to the trainer to prepare for the pilot agency (of which lacking the knowledge and understanding of the treatment). The entire equipment was translated from English-leading to misunderstanding and readiness in budget management. Therefore, the team began to develop the curriculum, teaching media, and training for staff in 2003. In 2005, there was a policy to set up training in all health service regions. This led to the increase in the number of therapists throughout the country. Though problems occurred. Trainees could not treat patients in real-life situations. The team then added more practice hours. And in 2017, the team had studied and further developed the curriculum to make it consistent with all the changes. They adjusted the guidelines to be more modern-leading to the acceptance of being the nation's standardized curriculum. The operating results were extended to provincial hospitals throughout the country. With this, the government had pushed the policy of this type of outpatient treatment to be the standard treatment with the supporting budget.

In the beginning, 2 major obstacles were found. I) 79.4 % of patients dropped out-making therapists not confident with the quality of the program, leading to many departments stop giving this service, 2) therapists lacked the knowledge and correct skills. This led to the team to add a motivation strategy, curriculum development, knowledge, skill , and techniques transfer. And focusing on exchanging ideas, participation, and training from real-life situations. Furthermore, manual development and teaching media were made to make it understandable and suitable for Thai society context. Finally, it was put in the Service Plan of drug care in 2016.

From a huge reform of the Substance care system, Thailand's stakeholder participation under the advocation of PMNIDAT toward drugs dealing strategy leading to the evidence-based and contextual appropriate unique innovation especially the modification by use of oriental treasure; Buddish culture and norm. Over 15 years of implementation and nationwide spread of these interventions, it was proved as the mainstream valuable key activities and allocated to all health care units around 1,000 places throughout Thailand, the result is acceptable in the national and international standard even though it's modified from the original but the main spirit is mostly complete remaining.

The development of the original Matrix program in Thailand has been dynamically changed over time, the process of developing and learning gradually increases its value by the working group analysis, synthesis, trial and experimental systemically. Successful with the program in the real-life situation cannot make it happen without the true understanding of Thai’s people lifestyle and finding out the best solution to fit in the context, despite keeping the scientific conceptual framework. This is the true challenge that has been shown how the creation of all stakeholder involvement.

Since the year 2002, after adopted the Matrix program into the best fitting performance measurement. The result clearly showed the significant reduction of relapse rate from 80 to 20 percent. Finally, the government declares this unique adapted intervention as the mainstream treatment protocol, while we are still developing the better version that’s effective, costly, easy to understand, well-designed package session by session. Instantly to use is the best answer to use wisely and ready to distribute into the domestic health care, non-health care alliance and the international user who has the same context and culture, such as ASEAN country, including Lao, Cambodia, Myanmar, Malaysia and Bhutan. All of these countries have got the technical support and supervisor by in house training, online consulting, inviting classroom programs the result is satisfactory. Even though there is the main treatment intervention In Thailand already, but for the sustainability reason PMNIDAT decided to incorporated this Modified Matrix program into a must listed minimal requirement of all treatment facilities by rule and the well-organized level of care called “ service planning” to guarantee the society about its standard, accessibility, equity to every people in the Kingdom that no one left behind, destigmatization and reduce discrimination.

After the first two years since the year 2002, it's introduced to the training of trainer program to prepare the next scaling up from the pilot site into the rest. We found many problems when we tried to implement and expand these modified interventions. For example, the different knowledge backgrounds, the capability to understand, insufficient learning instruments and the most important of resource allocation. This is the big challenge for Thai’s government to deal with a limited duration and high demanding to get people into the treatment, after indicating how the importance of training and resources preparation they decided to invest the budget and launch the policy of rapid distribution in all areas. Until now, not only the continuous improvement of the program content but also the coverage of capacity building to all health care providers both government and private (all 928 districts of Thailand). More than that, we try to expand the capacity building into non-health care alliances such as the educational sector, factorial, probation office, detention center and communities. At the present day, more than 1,200 staff who have got trained and planning to expand more 9,652 primary health care units throughout the nation within the year 2022.

Comprehensive and coverage services, requires collaboration from many sectors, including - Personnel team: Multidisciplinary team has designed, developed programs and transferred knowledge to practitioners in the treatment settings nationwide. - Budget: 1. Special budget based on the Narcotic affairs section, Universal Health Security Office and ministry of Public Health for the purpose of developing the program, create manuals and training for trainers. 2. The normal budget for treatment purposes, supporting by the government via the provincial Public Health Office as a local execution. The government supports an outpatient program budget of 3, 500 Baht/person.

This treatment has been in operation for over 19 years and is still ongoing, which is considered a sustainable treatment form as a result of consistent legal and therapeutic treatment policies. By changing the point of view from drug users into the term of patients who need to be treated. The treatment that corresponds to the situation, context, and needs of the patient and family, which is a patient-centered treatment that is suitable for the way of life of the patient, until the patient can live in the family and society without causing an impact on themselves and others.

Yes

Domestically evaluations were performed monthly from 7 pilot units in the year 2000-2001) with an annual external evaluation of the authorized Matrix institute, USA. Results have been found that the treatment outcomes were satisfied both qualitative and quantitative (many patients in this program reached 1 year abstinent). The overall result of 19-year implementation has been evaluated over time via the advocated outcome evaluation as the National indicator. All ministry was involved with clear activities directed to the same goal to make good remission, retention and enhance the community participation. In 2020 PMNIDAT planning to evaluate the program efficacy again.

In the beginning, treatment program evaluation was performed only in PMNIDAT and Thanyarak hospital branch (Chiangmai, KhonKaen, Songkhla). The current assessment of the system performed every trimester by use of the formal inspection questionnaire, the effective electronic record system which is shown the real-time treatment status nationwide. Indicators include patient satisfaction level, remission rate and retention rate, the number of accredited drugs treatment facilities, average unit cost and a total number of treatment places (government/private sector).

According to the assessment results from 2000-2002, it is found that Thailand does not have a clear drug treatment policy (focusing on suppression rather than treatment), the number of public and private hospitals is not enough to meet the need for treatment. The limitation of supporting systems such as congested location, not enough personnel, lack of trust in the treatment efficacy and limited financial support. However, when the program was continuously improved since 2003, it was found that 85% of patients were satisfied with the treatment. 96.5% of patients have a better family relationship, 95.8% of patients can stop using the drugs during treatment. In the following years, therefore, expand operations throughout the country until the beneficial results are as follows. 1. The Modified Matrix program is accepted and established as the national standard of treatment. Resulting in more accessibility. Community hospitals across the country can provide this service. 2. Optimal treatment: Reduce the cost of treatment 2-8 times compared to inpatients. Increasing the most appropriate resources utility, for all types of substance. 3. Increase the effectiveness of treatment: Reduce the rate of relapse, increase the rate of retention and reduce the country’s problem of economic, social and crime.

Since the year 2000, the government has been set up the committee, involving 14 stakeholders, for the purposed of knowledge management, program development, media development altogether. detailed below -Ministry of Public Health serves as policy advocacy and resources support to treatment facilities (PMNIDAT and regional Thanyarak hospital, mental health hospital, Bangkok health care center) and academic mission of PMNIDAT and Thanyarak hospital to develop the better effective program, training and research/technology assessment, continuously of quality improvement. -Hospital-based both government and private sectors opened up the Modified Matrix outpatient program, resulting in a term of accessibility and convenient enhancing. -The office of narcotic control board gives all support and governance the financial system with integrated all stakeholders as sustainability. -After long term advocates the human rights and chronic disease model of addictions to The government. Ministry of Justices takes a role to divert and discriminated peoples who needed the treatment program both outpatient and inpatient settings, including incarcerated program. Ministry of Interior takes the role of local support, finding out and motivate the case for entering the treatment program both outpatient and inpatient and strong focusing on the continuum care based on community environment, for the sustainable development of social strengthening.

The outpatient treatment program is designed to have patients, their families and communities to be part of the rehabilitation which will take Thai culture, social norm and patients’ way of life into consideration. -Ministry of Public Health, Ministry of Justice, Office of narcotic control and Medical services department will planning, funding and management through the hospital substance abuse clinic accreditation and standardization for the sustainability of addiction care - Local health care providers will take the plan into action and make sure that patients and their families will get the most benefit, finding the right treatment, according to the severity of the patient’s condition, reducing treatment time and saving cost. -Other government and private sectors, such as the Ministry of Justice will use the modified program both institutional and outreach into the risky group, they will use in 3 systems available in Thailand (voluntary, compulsory and correction).

The lessons learned from this program 1. The adoption of any intervention, especially psychosocial intervention, which is needed very comprehensive context-based modification because there were a lot of different from person to society. 2. The participatory action plan is needed to enhance the quality of care among patients, family and community because there are too many real-life factors that should be concerned and improved continuously. 3. The government should be prepared and supported all resources ( staff, kinds of stuff, financial, and good governance) for the most sustainable benefits to all addicts and their circumstances. 4. Communication and literacies alignment between policy makers-staffs-public is needed crucially. 5. This context-based modified out-patient program is more superior to other types of intervention in terms of real-life situations learning and growth of addicts. 6. These out-patient style interventions have more opportunities for integrated community-based and harm reduction approach to addicts.