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

  • In East Asia there is a paucity of systematically collected epidemiological data on drug use and dependence. Most of the available information stems from registration systems which underestimate the magnitude of the problem. Based on the available information, it is estimated that 3.3 million people use heroin in East Asia and the Pacific. Approximately seventy percent of them are in China. Annual prevalence estimates of methamphetamine among adults in 2010 range from 2.1% in the Philippines to 0.1% in the Republic of Korea. Lao PDR and Thailand, with the highest prevalence rates in Southeast Asia, have an annual prevalence of 1.4%, followed by Cambodia and Malaysia (0.6% and 0.6%). Based on available survey data, the number of crystal methamphetamine users in East Asia and the Pacific is estimated to be around four million, with China and the Philippines accounting for much of this total. Approximately 1.25 million people consume methamphetamine in pill form (yaba).
  • Available data suggests that the number of people who inject drugusers (PWID) in the region is in the range of 2-3 million. Most of them are in China (2.35 million), followed by Viet Nam (193,000), and Malaysia (177,000). Myanmar and Indonesia are estimated to have around 75,000 and 40,000 in Thailand (in Thailand most people who use drugs consume methamphetamine, which is rarely injected). Better estimates and information on drug use patterns and consequences are required, as well as user profiles, to better inform service planning, delivery and evaluation.
  • 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 the rapidly increasing use in others (China, Myanmar, Viet Nam) presents a significant challenge to the delivery of evidence-based services for people who use drugs. ATS use is highest in urban and border areas, and is increasing among youth in major cities. This is compounded by increase in the availability of other drugs such as cocaine, ecstasy-like derivatives, and synthetic cannabinoids. While there are well-developed intervention packages and pharmacotherapies for opiate dependence in the region, that is still not yet the case for ATS or other, newer substances in the region.
  • Use of compulsory centres for drug users (CCDUs) continues to prevail in the region. Faced with increasing illicit drug use, particularly of amphetamine-type stimulants (ATS), and persistent use of heroin and plant-based drugs, governments in East and Southeast Asia currently detain an estimated 238,000 people in some 1,000 compulsory centres. Throughout the region there are concerns about reported violations of human rights violations, sub-standard conditions, forced labour, physical and sexual violence, lack of access to health care in such centres and an increasing awareness that CCDUs fail to address drug use as a chronic relapsing health disorder. This has led governments to explore evidence- and rights-based alternatives to CCDUs.
  • Since the 2010 agreement between the Royal Government of Cambodia and the UN system to promote voluntary based access to drug treatment, no new centres have been opened in Cambodia. At least one centre for each province had been envisaged before the agreement. The key challenge to reaching the ultimate goal of closing the centres is the mobilization of the financial and technical resources required to scale up community based treatment and divert patients away from the centres.
  • Nonetheless there is increasing awareness and recognition of the limitations of CCDUs in addressing drug use as a chronic relapsing health disorder and in some countries the number of drug users in CCDUs is reported to continue to decrease (Malaysia and Viet Nam).
  • There is still a lack of funding to support the growing interest on the part of member states 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, develop approaches to stimulants particular to the region, share regional experiences and lessons learnt, and evaluate new initiatives to demonstrate the effectiveness of community-based approaches.

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Implications for the future

Data challenges

Data on the prevalence of illicit drug use and trends remain limited, and in many cases based on one single indicator (registration), which tends to be an underestimation. Adequate resources need to be allocated to collecting and sharing robust empirical data, that information is shared and used to inform responses

 

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.

 

Focus on community-based treatment

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. Approximately 238,000 people who use drugs are detained in some 1,000 compulsory centres in East and South East Asia. Compulsory centres constitute a complex phenomenon as well as a challenge with serious public health, human rights and rule of law implications.

In March 2012 twelve United Nations agencies and entities, including UNODC, issued a Joint Statement calling on States to close compulsory drug detention and rehabilitation centres and implement voluntary, evidence-informed and rights-based health and social services in the community.

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 2012.

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.
 

Regionally-relevant models for ATS treatment and care are needed

The use of opiates has stabilised in the region, while the use of methamphetamine and other new substances is increasing. There are internationally-tested psychosocial interventions for ATS use and dependence, however, these have not yet been validated in South-East Asia. The treatment and care systems need to develop, expand and adapt to the needs of drug users and people suffering from drug dependence, taking into account patterns of use and profiles of people who use drugs (mostly young men living in urban environments, pronounced gender gap, risk of under reporting of female drug use). 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 2012 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.

Six countries in the Mekong Region have approved a proposal aimed at fulfilling these knowledge gaps for treatment, and new initiatives aimed at regional networking and mentoring have been developed. Such initiatives would require renewed sources of funding yet to be identified.
 
Need to develop human resources The treatment of ATS dependence relies on 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 regional networking, training, support and mentoring.

 

Implications for follow-up in 2013 and beyond

South-East Asia currently presents 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, compulsory centres for drug users whose efficacy is not borne out by the evidence, and progressive development of community-based services for people who use drugs.

In 2013 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 models integrated in existing health and social welfare systems.
  • 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.
  • Promote networking among countries in the region in order to bring together and disseminate lessons learnt from developing community-based good practices, in particular with respect to ATS users.
  • Facilitate South-South cooperation, mentoring and mutual technical cooperation/exchange within the region and also with recognised centres of expertise in other regions.
  • Build the capacity of practitioners to deliver psychosocial approaches effective for ATS users.
  • Support the evaluation and quality improvement of existing programmes, in particular MMT and community-based treatment for ATS.

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