CHALLENGES IN METHADONE MAINTENANCE THERAPY

NAZIAH BT MOHD. NAZRI Pharmacy Practice and Development Division Pharmaceutical Services Division Ministry of Health
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WHY HARM REDUCTION

To reduce the transmission of HIV infection among the IDUs and partner

12th. April 2006: CABINET APPROVAL

1. National Strategic Plan on HIV/AIDS

6 MAIN STRATEGIES 1. Strengthening Leadership and Advocacy 2. Training and Capacity Enhancement 3. Reducing HIV vulnerability among Injecting Drug Users (IDUs) and their Partners 4. Reducing HIV vulnerability among Women, Young people and Children 5. Reducing HIV vulnerability among marginalized and vulnerable groups 6. Improving Access to Prevention, Treatment, Care and Support
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The 3rd. National Strategy on AIDS

Reducing HIV vulnerability among Injecting Drug Users (IDUs) and their SEX Partners

Harm Reduction in Malaysia

1. Methadone Maintenance Therapy

2. Needle Syringe Exchange Program 3. Safe Sex (Condom use)

For the HIV+ve and those who have sex with HIV+ve or unknown HIV status partners

VOCATIONAL COUNCELING DRUG REHAB JOB PLACEMENT

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ARV Rx.

STD Rx.

SOCIAL WELFARE

HEALTH & MEDICAL CARE

ESTIMATION ON HIV/AIDS IN MALAYSIA

Without intervention- 300,000 HIV/AIDS cases by 2015
300,000

Projection Of cumulative HIV/AIDS cases

100,000

With intervention

year 1985 2005 2010 2015

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Projected HIV Prevalence by 2015: 1.3% - Estimated PLWHAs: 188,838

HARM REDUCTION STRUCTURAL PROGRAM

Chaired by Director of Disease Control

NTFHR

National Task Force on Harm Reduction

Harm Reduction Program Manager

AIDS/STD, Section (Secretariat)

MoH / MAC / NADA / Police Force / JAKIM (dept of Islamic Dvp) / NGOS / Prison Dept/PLWHAs /

Implementing Agencies

Monitoring & Evaluation

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HARM REDUCTION STRUCTURAL PROGRAM

State Level : Harm Reduction Committee Chairman : Director of State Health Department MoH / MAC / NADA / Police Force / JAKIM (State Religious (Islamic) Dept) / NGOS / Prison Dept/PLWHAs / District Level : Harm Reduction Committee Chairman : District Health Officer MoH / MAC / NADA / Police Force / JAKIM (State Religious (Islamic) Dept) / NGOS / Prison Dept/PLWHAs
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Harm Reduction Strategies

1. Advocacy and Capacity Building.
Forum / Seminar / Media / training study tour / Research/Publication of IEC

2. Service that is client-friendly 3. Use multi-sectorial approach to implement harm reduction. 4. Use community based approach. 5. Practical Guidelines & SOP 6. Evidence-Based program implementation 7. Effective monitoring and tracking program. 8. Comprehensive Harm Reduction program.
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Collaboration : Key Stakeholders

Ministry of Health Malaysia (MOH) State Health Department & District Health Office, Legal advisory Universities Private Practitioners Royal Malaysian Police (PDRM) National Anti Drug Agency (AADK) Department of Islamic Development Malaysia (JAKIM) Malaysia Prison Department Malaysian AIDS Council (MAC)
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DRUG SUBSTITUTION THERAPY (DST) WITH METHADONE

Piloted in October 2005 at 10 fasilities and has expanded since then Drug : Methadone (in liquid form taken orally) Carried out at hospital and clinic (government as well as private) Community Center Prisons Buprenorphine Substitution Therapy General practitioners
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based

Drug

Rehabilitation

DRUG SUBSTITUTION THERAPY

Drug Substitution Therapy (DST) is one of the components of Harm Reductions for drug addicts which basically aims at preventing or reducing the negative health consequences associated with their risky behaviors of injecting drugs. Substitution Therapy replaces dangerous drugs such as heroin and morphine with prescribed medication of similar action but of much lower addictive or sedative effects.

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Operational Documents
MMT MMT Policy & SOP MMT Guidelines MMT Training Modules 7 Maklumat Penting Terapi Gantian Methadone Garispanduan Pendispensan Rawatan Terapi Gantian Methadone Garispanduan Kaunseling Methadone

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Maintaining opioid dependent individuals on methadone has many benefits: Reduced illicit drug use Improved health status as a result of access to treatment Decreased transmission of HIV, HCV, HBV Decreased illegal activity Increased employment Decreased cost to society Decreased mortality
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Achievement of MMT
(Disease Control Div, MOH)

MMT Facilities Hospital Health Clinic G.P NADA Prison Others Total

Number of MMT Facility (Cumulative by Years) 2006 8 2 7 0 0 0 17 2007 25 32 9 0 0 0 66 2008 27 32 9 3 4 0 75 2009 35 77 14 24 12 0 162 2010 40 134 21 25 18 2 240 2011 (June) 45 154 22 29 18 2 270
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Achievement of MMT
(Disease Control Div, MOH)
2011 (June) 25,000 2,572 18,441 2006 Target (Cumulative) No. of registered patient (Annual) No. of registered patient (Cumulative) No. of Active Patient (by end of the year) Retention Rate 1,200 1,241 1,241 2007 5,000 2,777 4,018 2008 10,000 3,047 7,065 2009 15,000 3,665 10,730 2010 25,000 5,139 15,869

932 75%

3,242 81%

5,024 71%

7,455 69%

10,664 70%

12,172 76.7%

HIV status : HIV +ve = 15.8% (2,803 Patients)

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Achievement - MMT
Employment among MMT pt - increasing; 47.6% to 66.3% after a year enrolled in the program (MoH,2006). 70.1% to 77.6% after 2 years (Ramli et all, Asia-Pacific Journal of Public Health, 2011) Urine positive for opiate decreasing ; 45% to 3% after a year enrolled in the program (MoH,2006). 2.4% to 1.4% after a year (Ramli et all, Asia-Pacific Journal of Public Health, 2011) Improving quality of life (Source : 1. MoH Malaysia , 2006; 2. WHO, Country Cooperation Strategy 2009-2013, 2010; 3. Asia-Pacific Journal of Public Health, 2011)
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 Opiate addiction has shown decreasing trend, from 67% in 2005 to 50% in 2010.

Behaviour changes in IDU (IBBS 2009) Percentage of IDU sharing Needles decreased - 12.7% in 2009 compared to 42.1% in 2004. Frequency of IDU sharing injecting equipment more than 5x a week decreased - 2.3% in 2009 compared to 15.9% in 2004. IDU has better knowledge on HIV/AIDS
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 40% reduction of new HIV cases (as compared to 2005)

8000 7000 6000 5000
4198

First case of HIV : 1986 Cumulative HIV (2010) : 91,362 AIDS : 16,352 Death : 14,298 PLWHIV : 77,064
4597 3924 4624 4692

6978 5938 5107

6756 6427 6120 5830

4549 3692 3080 3652

4000
3393

3000 2000 1000 0

3 2 9 200 778 1794

2512 2507

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

HIV

AIDS
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2010

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1. MORE PATIENTS, MORE MMT CENTRES

Year
Targets Coverage

2009

2010

2011

2012

2013

2014

2015
72,000 60.0%

15,000 25,000 35,000 45,000 55,000 65,000 12.5% 20.8% 29.2% 37.5% 45.6% 54.2%

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 Government Facilities
expand to Sabah & Sarawak Establishment of more HR facilities by 2015, all health clinic will provide HR services

more hospitals to provide MMT services More service centers for MMT are we ready?

SPUB Private pharmacies

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2. Manpower and facilities

Manpower pharmacists, doctors, counselors? Facilities treatment clinic, dispensing area

Pharmacists in health clinics - involvement of private pharmacists

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3. DRUG USERS
Polydrug users Abuse of substitution therapy esp with

buprenorphine and buprenorphine/naloxone Increasing trend of Amphetamine Type Stimulants (ATS) and other synthetic drugs Combination Chronic Diseases HCV, HBV, HOV/AIDS, TB Drug treatment :-drugs interaction (4%)*

* data Jan-june 2010

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4. Maintaining the patients

Maintaining the patients - ~30% defaulters Cannot be traced 34.4% Harassment from law enforcement esp PDRM Imprisonment no continuation of the treatment Logistic problem ie location Financial Health problems Unsuitable operating hours Work problems Drug taking 2.3 Transferred -0.3 PUSPEN 0.3
Source CDC, MoH 2008 24

31.5

31.2

5. Networking
Effective networking & referral systems

between various participating agencies between MoH, NADA, Prison, NGOs, GPs National Registry for complete database of DST patents and their treatment ie MyDST One stop center and management of comorbidities such as HIV,TB, Hepatitis B & C, Sexually Transmitted Infections, endocarditis etc.
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6. Products
Price in GPs Quality of products

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7. Motivation
Lack of understanding about MMT of top

management level Need motivation constantly Go for an extra miles..

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8. Changing Attitudes
Healthcare provider Patients

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9. Continuous Awareness on Harm Reduction

More awareness programmes on HRP Stigma from the community Lack of support form patients families NGOs participation in reducing harm of

drugs to society

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10. Monitoring and Evaluation

Is very important to know where we are More study nationally

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CONCLUSION
Harm Reduction has proven to be successful in Malaysia. Strong political support (including financial) Increasing number of HR centers but still requires more centers expansion More manpower For better impact on the effectiveness of MMT

Coverage of Harm Reduction (MMT & NSEP) need to be up scaled to achieve ~ 60% of IDUs (80,000 120,000).
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Commitment and collaboration among stakeholders need to be further strengthened.

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