Drug Demand Reduction

Essential problem

Lack of capacity and standards of good practice


Drug abuse in the region continues the general pattern and trend of the recent past. ATS, opiates, and cannabis are reported as the most prevalent and problematic drugs. Brunei, Cambodia, Lao PDR, the Philippines and Thailand, cite methamphetamine as the leading drug of concern. The crystal form of this drug, popularly known as shabu, is reported by Brunei and the Philippines as the exclusive type of methamphetamine which is abused. On the other hand, Cambodia, Lao PDR, and Thailand report methamphetamine pills - known on the street as yaba or yama - as the common form of the drug. Among the ASEAN countries, only Thailand cites abuse of both the pill and crystal forms of methamphetamine. All other countries report only one form. In addition to methamphetamine, the ATS drug ecstasy is reported as a drug of concern and is ranked as one of the top three drugs of concern by Brunei, Indonesia, and Viet Nam. While several countries rank methamphetamine as the leading drug of abuse, four - specifically China, Malaysia, Myanmar and Viet Nam - list heroin as the number one problem. Buprenorphine, a narcotic analgesic, is cited as the leading drug of concern in Singapore. Another major drug of abuse, and one with the highest abuse prevalence in many countries of the world - cannabis - is ranked top by Australia, the South Pacific Islands and Indonesia and ranked second by five other countries. The results of recent surveys in the Philippines, Thailand and Lao PDR have drawn attention to the widespread abuse of volatile substances such as glue, primarily by children and teenage youth. Inhalant abuse could well become a problem also in other countries in the region. Inhalant abuse is a major gateway to the abuse of other drugs, mainly amphetamine-type stimulants and heroin.

The key drug demand reduction gaps in East Asia and the Pacific include:

  1. Prevention:
    a. Insufficient prevention efforts to deter experimentation or at least delay onset primarily among at-risk youth.
  2. Treatment:
    a. Inadequate care and support for drug users.
    b. Inadequate trained manpower to deliver services (especially in the case of ATS) and ill-equipped training centers.
    c. Insufficient community/voluntary treatment centres as an alternative to compulsory treatment centres/imprisonment.
    d. Inadequate minimum standards of care and support.
  3. Reintegration:
    a. Insufficient community-based reintegration and aftercare programmes.
    b. Ineffective drugs laws and policies geared to respond to drug use offences.
    c. Insufficient legal "coverage" for vulnerable groups within the criminal justice system.
    d. Inadequate capacity-building for police officers.

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Strategic concerns

  • There remain few evidence-based, effective drug prevention programmes in the region.
  • As in prior years, the high prevalence of ATS use in some countries (Cambodia, Lao PDR, and Thailand) and rapidly increasing use in others (China, Myanmar, Viet Nam) presents a significant challenge to the delivery of evidence-based services for drug users. While there are well-developed intervention packages and pharmacotherapies for opiate dependence in the region, that is still not yet the case for ATS.
  • Use of compulsory centres for drug users (CCDUs) continues to be prevalent in the region. Nonetheless there is increasing awareness and recognition of their limitations in addressing drug use as a chronic relapsing health disorder and in some countries the number of drug users in CCDUs is reported to have decreased (Malaysia and Viet Nam).
  • There is a lack of funding to support incipient interest by countries in the region to test and scale up alternatives to CCDUs. Funding is required to provide intensive training and mentoring to ensure adequate quality of services, as well as proper evaluation to be able to demonstrate the effectiveness of community-based approaches.

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Implications for the future

Evidence-based prevention initiatives need to be adapted and implemented in the region While there are internationally-tested family and school-based prevention initiatives, these have not yet been tested in most countries of the region. At the same time, Governments are concerned about drug use among youth and commit resources to interventions which have not shown effectiveness. In response, a groups of six countries in the Mekong Region approved in 2011 a project concept aimed at adapting and piloting two evidence based prevention programmes. This initiative has yet to secure funding.

Continued need to put public health back at the centre of drug control Drug dependence is a chronic, relapsing health disorder and should be dealt with based on scientific evidence and on each individual's needs. This is a part of every individual's right to health. In addition, drug treatment responses should be tailored to the severity of addiction - for example, not every drug user needs treatment. Indeed, formal or residential treatment is not likely to be the most adequate response for the majority of drug users. The development of community-based treatment programmes should be pursued as an alternative to the existing approaches.

Regionally-relevant models for ATS treatment and care are needed While there are internationally-tested psychosocial interventions for ATS use and dependence, these have not yet been validated in South-East Asia, where ATS use is both on an upward trend and also represents the main treatment demand in several countries in the region. Intervention models that take into account the different needs of ATS occasional, regular and dependent users, as well as the operating environment in the region, need to be developed and evaluated. While progress has been achieved in 2011 in this area, much still needs to be done in terms of training, mentoring and rigorous evaluation in order to provide the level of required for commitment to large scale implementation. In 2011, six countries in the Mekong Region approved a proposal aimed at fulfilling these knowledge gaps for treatment, however, such initiative would require renewed sources of funding yet to be identified.

Compulsory centres versus community-based voluntary treatment Because there are, as yet, no tried-and-tested psychosocial interventions for ATS which have demonstrated effectiveness in the region and because ATS have now become the most frequently use drug in many countries, this sets important limitations on the transition from compulsory centres to community-based and evidence-informed approaches. Consequently some government partners remain hesitant about embarking into untested waters and often feel under pressure from communities to retain what is perceived to be a community safety perspective on compulsory treatment.

Nevertheless, there is an emerging shift in attitudes and practices in some countries. For example, the shift from compulsory centres to 'Cure and Care' clinics in Malaysia initiated in June 2010 continued in 2011 and is currently under evaluation.

The development and sustainability of a community-based treatment system requires cross-sectoral collaboration and integration into health and social welfare systems, including linkages between methadone maintenance services (usually provided by the health system) and other drug dependence services (frequently provided by other partners), as well as a healthy collaboration with law enforcement services in order to create an enabling environment.

Community-based treatment proposal for Cambodia The plan for implementation of community-based drug treatment services in Cambodia, supported by high-level Government authorities and the full UN Country Team, presents a unique opportunity to develop and demonstrate a new approach to ATS use and dependence not only for Cambodia, but for the region as a whole. However, despite intense fund-raising efforts by the Government and UNODC in 2011, as well as a financial allocation from the National Health Strategic Plan and much welcome contributions from Sweden and the USA, a critical level of funding has yet to be secured.

Need to develop human resources The treatment of ATS dependence relies of psychosocial approaches, which are heavily dependent on well trained and empathic counsellors and case managers. Countries in the region typically lack a trained workforce in these areas and therefore it is imperative to allocate sufficient resources to ongoing training, support and mentoring.

 

Implications for follow-up in 2012 and beyond

In South-East Asia, we currently have a patchwork of developing good practices consisting of community-based voluntary services which integrate methadone maintenance therapy for those who are opiate dependent, expanding methadone maintenance clinics which need to strengthen their technical quality, and compulsory centres for drug users whose efficacy is not borne out by the evidence.

In 2012 and beyond UNODC will therefore continue to:

  • Advocate for public health to be put at the centre of drug control policies and for mutisectoral collaboration for the development of community-based drug dependence treatment systems integrated in existing health and social welfare systems.
  • Support the finalization and adoption of  tools for system development: models of service delivery, standards of care and guidelines.
  • Support the development and expansion of community-based services for drug users, and in particular actively pursue the Cambodia community-based drug treatment proposal already developed.
  • Bring together lessons learnt from developing community-based good practices, in particular with respect to ATS users.
  • Build the capacity of practitioners to deliver psychosocial approaches effective for ATS users.
  • Facilitate mentoring and mutual technical cooperation/exchange within the region and also with recognized centres of expertise in other regions.
  • Support the evaluation and quality improvement of existing programmes, in particular MMT and community-based treatment for ATS.

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