Methadone Maintenance Treatment of Heroin Abuse in China

Following British importation of opium to China in the 1760s, the use and production of the drug in China increased dramatically. Before the establishment of the People's Republic of China in 1949, approximately 5% of the entire populations of mainland China (approx. 20 million people) were addicted to opium. Following a 1949 national antidrug campaign, China became “a country free from drugs” ([1], [2]). However, China has been facing the recurrence of pandemic heroin abuse since the late 1980s with users spending over 36 billion U.S. dollars in 2006 ([1], [3]). Furthermore, 50%–70% of heroin users are at high risk for HIV and hepatitis due to drug injection ([1]). The purpose of this article is to review the drug abuse and HIV/AIDS epidemics in China and the Chinese government policy for methadone maintenance treatment (MMT) as a response.

EPIDEMIOLOGY OF DRUG ABUSE

In the late 1980s, opiate abuse was limited to young, poor farmers in the southwest and rural areas in the northwest. However, with the open door policy of the early 1990s, drug use has spread from the Golden Triangle region to the urban population and includes 73% of the counties, cities, and districts in China, with 1.16 million registered and an estimated 3.5 million drug abusers in 2006 ([4], [5], [6], [7]). Addicts are predominantly single males under age 30 with low levels of education and employment ([6]). Most (78%) are dependent on heroin with the highest rates in Yunnan, Sichuan, Guangxi, and Guangdong provinces ([7]).

The ratio of injection (IVDU) to inhalation drug use has remained high in China, especially in Sichuan (Xichang City), Hubei, Gansu, and Guangdong (Guangzhou City) Province with 50 to 70% IVDU and 25 to 50% inhalation users. Inhalation is called “chasing the dragon” or “Zhuilong” in Chinese, which means ingesting the drug by inhaling the vapor that forms when heroin is heated. Although many new heroin users begin by sniffing (55%) and sometimes smoking (8%) the drug, habitual users generally inject heroin presumably for greater efficacy at lower doses and cost ([8]). Most registered heroin users shift from sniffing/smoking to injection after about 50 episodes of heroin use ([9]).

Abuse of amphetamine-type-stimulants (ATS) including amphetamine, methamphetamine, and ecstasy (MDMA) is increasing and has further complicated this epidemic since the late 1990s, particularly in southeastern and business-centered cities ([3], [4], [10], [11]). While most ATS users are young, jobless people under 35, like heroin abusers, growing numbers of users are from stable social groups like business people, entertainers, and students ([12]). This increase in ATS use has not only shifted the abuser demographics, but also decreased the proportion of heroin users from 88% in 2002 to 78% of all drug abusers in 2006. ([6], [7], [12]). However, heroin is prevalent and causes more severe health and social problems than ATS.

EPIDEMIOLOGY OF HIV/AIDS

Drug abuse among IVDUs has been a key factor in the spread of HIV/AIDS in China ([13]). The first Chinese AIDS cases involved foreign travelers starting in 1985, with 17 more cases by 1988 ([14]). The first drug-related HIV infection was reported in Yunnan Province in 1989. Soon after, 146 cases were detected among IVDUs in southwest Yunnan Province ([15]). Since 1994, HIV/AIDS spread rapidly from drug abusers to the general population, and by November 2006, China reported 183,733 HIV infections, including 40,667 AIDS cases with 12,464 deaths. Currently up to 1 million people in China are living with HIV, and 80,000 have developed AIDS ([16]).

Needle sharing is the main transmission route of HIV/AIDS in China, and a survey from 1997–1998 among 3,015 heroin addicts in Guangdong found that 86% of the HIV-positive population were IVDUs, and that 89% of them shared syringes ([17]). The HIV infection rate in Guangxi drug abusers was found to be 36%, and 70% of those infected were IVDUs ([18]). Drug abusers in Xinjiang Municipality, Guangxi, Hubei, Hunan, and Guangdong Provinces share syringes at a rate of 60%–90% ([19]). The high HIV prevalence among IVDUs suggests that they will contribute to a rapid spread of HIV/AIDS in the general population, probably through sexual transmission.

The spread of HIV by sexual transmission, specifically drug-related prostitution and unprotected sex provides a bridge between injection drug users and general populations ([20], [21]). Over the past two decades, China's commercial sex industry and HIV infection rates have both increased dramatically ([22]).

MMT IN CHINA

In China, compulsory detoxification is the primary inpatient treatment modality for drug addicts, and most are given only acute detoxification treatment ([1]). Because 60%–95% of detoxified patients relapse within a year ([2]), the government has developed harm-reduction services, in particular MMT in provinces where opiate abuse is widespread and HIV infection has become a major concern ([3]).

The Chinese government has offered methadone-based withdrawal programs since 1993, and based on over 10 years of experience, the first 34 MMT clinics were set up in 2004, and by the end of 2006, more than 320 clinics had been opened, serving more than 36,000 patients. It is estimated that 47,427 cases were being treated by August 2007, and the number of clinics will likely reach 500 by the end of 2007 with a final target of 1,000 clinics serving 200,000 drug users ([3], [23]).

These programs have reduced injection drug use and criminal behavior, and improved social behavior ([23]). The first MMT pilot study in China reported in November 2005 found that program retention rates were 97% at 3 months and 85% at 6 months ([22], [24], [25]). The severity of patients' dependence was decreased by more than half, the depression rate fell from 51% to 33%, and employment increased from 25% to 31%. While the HIV (3.9%) and hepatitis C (46%) infection rates were stable, high-risk consumption patterns like injecting diminished significantly.

While these data have won support for MMT from physicians treating these patients, objections to MMT from general health care providers and the public about substituting one addiction for another has produced heavy regulation including strictly limited “take-home” of methadone outside of the specially licensed clinics. The policies are considerably stricter than in other countries like the United States and are one possible contributor to increasing problems with treatment retention due to the ongoing need for patients to attend clinics daily.

The relatively high (30%–40%) dropout rate from Chinese MMT programs must be addressed in order to decrease drug use, criminal activity, and unemployment ([26]). This high rate of attrition may be improved by greater involvement of nursing and therapy staff rather than simply pharmacy dispensing stations, and by a shift to more positive attitudes of staff towards this type of maintenance program ([22], [27]). Behavioral interventions are not commonly used in China's MMT, and motivational enhancement therapy and motivational interviewing could increase MMT's effectiveness. As another example, self-help groups like Narcotics Anonymous (NA) in Yunnan MMT sustained treatment success ([22]). Overall, the public and local governments are not convinced of MMT's efficacy and safety ([28]). Explicit support of the central government has successfully implemented some MMT programmes; local police have arrested drug users when attending MMT programs particularly in rural areas, where opiate addiction has had its earliest roots and highest rates.

In conclusion, heroin abuse is negatively impacting China's public health, economy, and social stability, and MMT programs have successfully mitigated harm related to heroin abuse ([24], [25]). However, changing attitudes towards MMT and increasing quality of psychosocial care within MMT are necessary to expand these harm-reduction programs throughout China.

This work was supported in part by the National Basic Research Program of China (973 Program, 2003CB515400), the National High Technology Research and Development Program of China (863 Program, 2006AA02Z4D1), and the China–Canada Joint Health Research Program (No. 30611120528).