Substance Dependence Treatment Interventions: Why We Continue to Fail People Who Use Drugs in Asia

Abstract

Introduction: Substance use disorders contribute to a large number of preventable deaths in Asia; a majority of the negative health consequences are associated with opioid use. User friendly and effective drug dependence treatment is limited. Scope: Factors mediating drug user treatment outcomes in Asia are explored, with a focus on opioid use. Individual, programmatic, and legal/political issues which reduce the impact of drug user treatment are noted. Discussion: Criminalization of drug users, inadequate insurance, chronic underinvestment, and an overall lack of therapeutic options create structural barriers for treatment for users and providers. The practice of detention as drug treatment serves to fracture the treatment alliance. At the individual level, extreme poverty and the lack of a social protection network mediate against the achievement of treatment goals. Conclusions: A range of factors has a bearing on processes and outcomes of drug user treatment. Acknowledging and addressing them, at each level, is fundamental to delivering useful interventions for people who use drugs.

Keywords :

• Asia, consumer advocacy
• Disability Adjusted Life Years (DALY)
• global disease burden
• medically assisted treatment (MAT)
• relapse
• retention
• under dosing

Notes

1 Treatment can be usefully defined as a unique, planned, goal directed, temporally structured, and multidimensional change process, which may be phase-structured, of necessary quality, appropriateness, and conditions (endogenous and exogenous), implemented under conditions of uncertainty, which is bounded (culture, place, time, etc.), which can be (un)successful (partially and/or totally), as well as being associated with iatrogenic harm and can be categorized into professional-based, tradition-based, mutual-help based (AA,NA, etc.), and self-help (“natural recovery”) models. Whether or not a treatment technique is indicated or contra-indicated, and its selection underpinnings (theory-based, empirically-based, “principle of faith-based, tradition-based, budget-based, etc.) continues to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) and “wellness” treatment-driven models, there are now new sets of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Conflict-resolution models may stimulate an additional option for intervention. Treatment is implemented in a range of environments; ambulatory as well as within institutions which can also include controlled environments such as jails, prisons, and military camps. Treatment includes a spectrum of clinician-caregiver-patient relationships representing various forms of decision-making traditions/models; (1). the hierarchical model in which the clinician-treatment agent makes the decision(s) and the recipient is compliant and relatively passive, (2) shared decision-making which facilitates the collaboration between clinician and client(s)/patient(s) in which both are active, and (3) the “informed model” in which the patient makes the decision(s). Within this planned change process, relatively recently in various parts of the world, active substance users who are not in “treatment” as well as those users who are in treatment, have become social change agents, active advocates, and peer health counselors…which represent just a sampling of their new labels. There are no unique models or techniques used with substance users—of whatever types and heterogeneities—which are not also used with nonsubstance users. The reality that substance users, representing a heterogeneous group of people, patterns of use, and life styles, continue to be treated in “specialized” programs which are distanced from the mainstream of the treatment of nonusers—“NORMED TREATMENT OF NORMED DISEASES”—and all-too-often manifest imparity in availability, accessibility, and delivery of needed services, utilize policies which are stakeholder—driven and not evidence-based and may be ethically insensitive, does not change the reality that there is no “drug treatment”; no “alcohol treatment.” Editor's note.

2 One needs to consider that “retention” rates have inevitably been associated with a range of professional treatment programs, whose quality have not been reported, who, by and large are abstinence oriented, with no generalizable data from mutual help or self-help (“natural recovery”) efforts or from programs based upon harm-reduction and quality-of-life ideologies. In addition, when the concept and process of treatment retention have been reported, this has most generally not considered the necessary critical conditions (endogenous as well as exogenous ones; micro to macro levels; rates of development as well as cessation) to operate as well as not to operate. Editor's note.

3 The policalization of substance use, the stigmatization of selected “drugs” and their users, has created its own semantics with a range of implications which can and do effect treatment planning, implementation, and assessment. For example, pharmacotherapy is a normed category for treating a range of chronic as well as nonchronic psychiatrically diagnosed diseases/conditions. The term substitution therapy or MATS is the normed category for the use of medication given to “drug users.” The term chemotherapy is used for patients being medicinally treated for cancer; insulin remains insulin when indicated for the treatment of people diagnosed with diabetes and nicotine patches are used for treating smokers…etc. Whereas drug users—people manifesting a substance use disorder—lapse or relapse following periods of nonuse, people diagnosed and treated for normed diagnosed diseases are related to as being in remission when their disease is not present/active. Relapsing focuses upon the pathology, remission focuses upon a nonpathological, or healthy state. The anticipated “relapse” is generally considered as being the responsibility of the relapsing drug user, whereas an active chronic disease as well as a state of remission are not the responsibility or the “fault” of the legitimately sick person. Interested readers are referred to Tilly, Charles (2008). Credit and Blame Princeton Univ. Press. Princeton, NJ. Editor's note.