Information about methadone, inpatient care centres only for drug users, and last priority for antiretroviral treatment.

Why is methadone not being scaled up faster, are inpatient centres the most cost efficient way to detox, and how does one know how many PWID are on antiretrovirals?

Jamie

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‘Treatment, not punishment’
Portia Larlee
Mizzima News
27 April 2014

The Asian Harm Reduction Network Myanmar office was established in July 2003 under a memorandum of understanding with the Ministry of Home Affairs’ Central Committee for Drug Abuse Control. The AHRN, which now works in cooperation with the Ministry of Health, has six drop-in centres and clinics in Kachin State and two in Shan State providing primary healthcare services, peer support, methadone treatment and harm reduction materials – such as clean needles and syringes – to injecting drug users. In 2006 the Better Shade Peer Support Program, formerly known as Black Sheep, was founded in Lashio. The program is now active at the eight AHRN project sites, with 24-hour peer-led care available at Lashio and Seng Taung. The network’s deputy national program manager, Ko Hlaing Min Oo, and its national health coordinator, Dr Aung Yu Naing, spoke with Mizzima Business Weekly’s Portia Larlee about harm reduction practices, peer support and the stigma faced by injecting drug users.

Why did you become involved in harm reduction?

Dr Aung Yu Naing: I am from Taunggyi [the Shan State capital]. When I was in medical university I learned one of my friends had been using drugs for a long time and was infected with HIV and hepatitis C. After graduation in 2007, I found a job at an AHRN project site in Laukkai where most people are Chinese and can't speak Burmese. I speak Chinese and was interested in harm reduction because of my background. I have learned addiction is not an easy thing. Everyone thinks drug users can easily stop using at any time. Actually it is very difficult and sometimes not realistic to ask drug users to stop using drugs. The World Health Organization says addiction is a chronic relapsing disease, so harm reduction interventions are needed. Drug users need to protect themselves and, by extension, their community.

Hlaing Min Oo: I started this work in 2004. I have the same philosophy. Addiction is difficult not only for drug users but also for a cigarette smoker like me. Unfortunately, for drug users, their addiction gives them more problems since it is illegal.

Why are the AHRN Myanmar project sites in the northern regions of Shan and Kachin states? What are the most common drugs used in these regions?

HMO: Historically, most poppy cultivation for the production of opium in Myanmar has been in Shan State. Also, there are drug trafficking routes in these regions. Heroin is the most commonly used drug in those regions. Amphetamines are also increasingly prevalent there.

How is outreach conducted?

HMO: We have outreach workers in all our project sites. They go to the places where they can find the drug users. This way they can be in contact with the individual clients and share health education. If required, they refer the client to our drop-in centre or clinics.

AYN: As an NGO running harm reduction programs we don't expose information that might negatively affect the people we work with. Whenever there are crackdowns, the drug users become more and more hidden. It is very difficult to find them and provide prevention materials. Of course, there are places [where users inject] – there is always a place. Some drug users may go to a ‘shooting gallery’, maybe some bushes or maybe the street. Sometimes the place is safe, sometimes not.

What changes have you noticed since beginning this work nearly a decade ago?

HMO: Methadone maintenance treatment is now increasingly available due to endeavours of the drug treatment centres of the Ministry of Health. This has had a significant impact on drug users and also the community. The life of the drug user has changed. They don't need to buy drugs or use [them] in unsafe conditions when they take methadone. They can save money, look after their family, find a job. Their socio-economic position changes. HIV rates … in our project areas have also gone down significantly since we started our prevention services, including needle/syringe programmes.

AYN: Generally users come to our clinics more and more. Before they were reluctant to access healthcare services because of stigmatisation or because of fear of arrest. But now they trust us. They can access our medical clinic and drop-in centre. At the drop-in centre you can watch television, play games, take a shower, participate in health education talks, interact with our staff and get counselling and prevention materials.

Describe peer support activities supported by AHRN.

HMO: In June 2006 methadone treatment started in Lashio. The participants were able to stop using drugs and started to organise themselves in the Black Sheep Peer Support Group. The black sheep are limited and stand out among the white ones. The community is white; the drug user is black. They gave themselves that name because they felt like black sheep. Though AHRN supports the group technically and management wise, they formed themselves and they have a board, a committee and members.

They started an income generation program. They work with many NGOs in Lashio to sell water purification systems and distribute them. This has been quite successful. They also created a network of 'care providers.' When someone in the hospital needs a care provider – someone to pick up medicine and food – the black sheep members provide day and night care for which they receive compensation.

AYN: In 2011 the Black Sheep group started a 24-hour care centre in Lashio with 15 beds. They call it buddy care; it is peer-to-peer care supervised by medical doctors and nurses. They started to expand this in Seng Taung in 2012 using the same model.

We also have centres which provide end-of-life care and funeral services. People who use drugs should be able to die with dignity like everyone else. In Myanmar drug users – especially injecting drug users – are last priority to be able to access life-saving medicine like antiretroviral treatment. There is a misconception that drug users will not adhere to treatment.

HMO: Black sheep members provide funeral services and cover all costs. They arrange everything in accordance with the religion of the deceased.

How does AHRN manage overdose cases?

AYN: We provide first-aid training to dealers and to drug users in the community. There are a lot of misconceptions about the management of overdoses. We provide regular training about detecting overdoes and how to manage them. Many drug users are afraid when they overdose it will become a police case and they might be jailed.

How does society respond to harm reduction?

HMO: We hear many criticisms, such as we are encouraging drug users to use more drugs through harm reduction practices. It is a controversial practice, not only in Myanmar, but internationally. Here in Myanmar we are working with the Ministry of Health, we are preventing HIV and other blood-borne infections. From a public health perspective this makes sense and some members of the community accept this strategy. We try to collaborate with community leaders and the government.

AYN: The attitude held by the community is 'say no to drugs.' But in reality this is very difficult due to the difficulties related to addiction. But harm reduction, including methadone maintenance therapy, is evidence-based and will help drug users re-enter the community. Until now the community and families of drug users still believe the only option is to stop using. They don't know that addiction is a brain disease, a chronic relapsing disease. It should be treated and not punished.

http://www.mizzima.com/opinion/interviews/item/11114-treatment-not-punishment