SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Post-its from Practice:
Thailand (May 2009)

I was asked to see Apinum whilst attending the 20th International Harm Reduction Conference in Bangkok. This year's title was "Harm reduction and human rights". He was unwell and complaining of a very painful thigh and a temperature.

Apinum has been an injecting drug user for over 12 years and a member of the amazing Thai Drug User Network for several years. I asked to see his leg and was confronted by cellulitis in a severely scarred leg. It didn't look like injecting damage, so through his interpreter I asked about the origins of the scarring. Apinum became acutely embarrassed, but eventually revealed that he had been tortured whilst in enforced drug treatment.

The first time I saw Apinum at the conference he was taking part in a protest march before the opening ceremony and the crowd was chanting "User rights are human rights, stop torture now" in English and Thai. People were carrying a series of different placards stating "Thai drug users are dying for harm reduction"; "Torture is not a cure"; "Treatment not torture for people who use drugs" and many other statements.

The three days between the protest and our consultation had been packed with learning, feeling and thinking. I had learnt that the human rights of people who use drugs are regularly violated and abused across Thailand and the whole of Asia. People who use drugs are routinely arrested, detained, beaten and forced into detoxification. In some countries treatment, which in most other places would be classed as torture, is compulsory. The death penalty is still legal in many countries and used for people who use drugs.

Although the effectiveness of harm reduction is undeniable, access to harm reduction services is between 2-5% in many areas of Asia - clearly, a contravention of human rights. As Manfred Nowak, UN's special rapporteur on torture so eloquently put it "Harm reduction IS human rights" and he spoke passionately about the need for a human rights-based approach to drug policy.

Apinum had experienced compulsory drug "treatment"(!) in one of the growing number of Thai military drug centers, which have had no evaluation and have a relapse rate of at least 96% in the first week post discharge. Thailand's official drug policy is that drug users are "patients" not criminals but the reality is very different.

But harm reduction has moved forward since I attended my 1st IHRA conference 12 years ago. The 2009 conference was opened by Professor Michel Kazatchkine, Executive Director of the Global Fund to fight AIDS, TB and malaria. He reminded us how "Alarming evidence was a principal tool for advocacy - with the life expectancy of someone beginning anti-retroviral medication 12 years lower for an IDU than a non-IDU". He went on to say how this "shows the scandalous failure to prioritise effective healthcare" and "no matter how often evidence is denied we must continue to maintain hope and keep up the fight". These sorts of statements used to be only made by us (people who use or have used drugs and workers) in previous years!

But all is not bleak in Asia. Many of the innovative harm reduction services are completely run by people who use or have used drugs, often in difficult circumstances with little or no funding: people distribute good quality information and clean injecting equipment from their homes or the back of their mopeds.

Apinum is a volunteer harm reduction worker and spends most of his time distributing injecting equipment and doing amazing health promotion work. He is 29 years old and has known he is HIV positive for 4 years. He has little access to HIV medication or pain relief. I was able to help his cellulitis with clarithromycin I had brought from UK, in case, and some tramodol for his pain*. He improved dramatically in 24 hours and the highlight of the conference for me was his amazingly polite and discreet thank-you (khdwp khun) as we parted to go back to our usual lives.

I learnt much more than I gave and am returning to UK feeling humble and remembering, even if we need to continue to fight for better treatment and resources, just how lucky we are in the UK with drug treatment and harm reduction services.

- Dr Chris Ford

* 80% of the world does not have access to effective pain relief