Content Methadone : what & why ? Outcome over 12 years Issues - PowerPoint PPT Presentation

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 the country ◼ Commonly used illicit substances are heroin, amphetamine, marijuana & designer drugs ◼ Methadone is one of medical treatment for heroin use

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 are achieved and an opportunity is provided for individuals to deal with major health, psychological, family, housing, employment, financial and legal issues while undergoing treatment. • Provides opportunities for early diagnosis of other health problems, HIV testing and counseling 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

Hypodopaminaemia Positron 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

HIV/AIDS Projection by 2015, Malaysia 300,000 HIV/AIDS cases by 2015 If no Effective intervention in place 300,000 Projection Of cumulative The expected HIV/AIDS reduction of cases HIV/AIDS cases 100,000 With effective intervention In place. YEAR 1985 2005 2010 2015 Estimated Prevalence: 1.3% - Estimated PLWHAs: 188,838

COMPONENT OF HARM REDUCTION 1. Education 2. Screening and medical treatment 3. Methadone Maintenance Therapy (MMT) 4. Needle Syringe Exchange Program (NSEP) 5. Safe Sex (Condom use) VCT SOCIAL WELFARE ARV Rx. COUNCELING STD Rx. DRUG REHAB HEALTH & MEDICAL CARE IEC JOB PLACEMENT

DST FACILITIES, MALAYSIA 2017 DST Number of DST Facility (Cumulative by Years) (Commenced : Oct 2011 2012 2013 2014 2015 2016 2017 2005) Hospital 48 49 53 55 55 55 53 Health Clinic 168 203 293 316 359 387 398 G.P (MoH 24 21 22 24 24 22 22 partnership) 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 365 366 375 401 369 382 382 TOTAL 811 838 857 674 715 907 889 Source : Ministry of Health, Malaysia

COVERAGE : DST PATIENTS 2017 DST (Commenced : Oct 2011 2012 2013 2014 2015 2016 2017 2005) No. of registered patient at Govt 5,086 6,801 5,688 4,111 3,710 3,064 2,811 Setting (Annual) No. of registered patient at Govt 20,955 27,756 33,444 37,555 41,265 44,329 47,140 Setting (Cum) No. of registered 23,257 24,324 31,805 37,261 patient at GP Setting 44,361 50,616 52,341 ** ** * * (Cum)* TOTAL 44,212 52,080 65,249 74,816 85,626 94,945 99,481 Source : 1. Disease Control Division, MoH Malaysia 2. * NDST Report, AMAM 3. ** 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

REPORTED HIV CASES ATTRIBUTED TO IDU, MALAYSIA 2000 - 2017 Notification rate No HIV 6,000 90 74.2 PREVALENCE 79.6 5,176 70.6 74.7 80 AMONG 4,796 5,000 4,724 69.7 PWID (IBBS) 70 66 4,478 HIV IDU 2009 22.1 3,815 4,038 57.3 Notification rate 4,000 60 57.2 53.6 % 55.2 50 3,127 3,000 47.6 2,601 2012 18.9 40 2,113 38.7 % 29.5 2,000 1,699 1,733 30 1,348 21.5 2014 16.3 19.3 16.8 1,014 20 % 728 680 1,000 11.1 561 377 3.44 10 2017 13.4 115 % 0 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Source : MoH Malaysia Year

MALAYSIAN METHADONE TREATMENT OUTCOME STUDY (MyTOS) 2016 NMRR: 13-1270-18045 ( 15 th May 2014) • MRG-MOH-2014-10 (28 th Aug 2014) •

MyTOS 2016 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

Status Status ( n=3254) Count Estimated % 95% CI Prevalence population Lower Upper Status Count Estimated % Prevalence 95% CI Dead 251 2373 8.6 6.8 10.8 population Lower Upper Defaulted 984 8030 29.2 26 32.4 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 Transferred 546 4831 17.5 14.6 20.8 Active 1234 10243 37.1 33.7 40.7 Active 1234 10243 37.1 33.7 40.7 Terminated voluntarily 221 1972 7.1 4.9 10.3 Terminated voluntarily 221 1972 7.1 4.9 10.3 Terminated involuntarily 18 138 0.5 0.2 1.1 Terminated 18 138 0.5 0.2 1.1 involuntarily

HIV risk, crime & health Items Mean ± SD Mean 95% CI t P n= 779 difference ± SE (before vs after) HIV Risks 6.22 ± 2.65 ± 4.27 3.56 ± 0.23 3.12 4.00 15.77 <0.001 7.24 Crime 0.30 ± 0.03 ± 0.28 0.30 ± 0.03 0.24 0.37 9.11 <0.001 1.10 Health 3.94 ± 2.22 ± 3.09 1.73 ± 0.13 1.47 1.98 13.37 <0.001 score 4.50

Blood borne viruses infection BBV n Baseline Current Positive Negative Positive Negative n (%) n (%) n (%) 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 Mean ± SD Mean difference ± 95% CI t P n= 779 SE (before vs after) 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 After MMT n (%) 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 Life Variable Mean ± SD 95% CI t P n= 905 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 Question: 3.1% 2.3% 6% In MMT, you 26.8% received assistance that Strongly agree Agree Not sure Disagree 61.9% Strongly disagree