From Mainlining to Methadone in Cambodia

By Zsombor Peter and Phorn Bopha
The Cambodia Daily
October 30, 2012

Ly Chan Long could not recall just when it was that he first tried to quit heroin on his own. He had been using for three or four years, and his first attempt soon failed. Dates were still hazy. But he had no trou­ble remembering what it felt like. 

“It was like 100 diseases were inside my body and like my bones were choking,” said the wiry 26-year-old with a thick, messy mop of hair and the scraggly first wisps of a beard.

Since joining a government-run methadone program for heroin addicts a few months ago he has managed to cut back to injecting once or twice a week, with almost none of the withdrawal symptoms. The program hopes to get Mr. Long off heroin altogether in a matter of months.

It is what the program has come to do well since Cambodia’s first—and, thus far, only—methadone clinic opened its doors at Phnom Penh’s Khmer-Soviet Friendship Hospital in July 2010.

Getting heroin addicts onto a daily dose of methadone and gradually off of heroin has been the clinic’s success. But in almost every other respects, the program is still struggling.

Both the clinic’s director and the NGOs he works with complain of stubbornly low enroll­ment, poor drug counseling and not enough help finding patients work and reconnecting them with family—the things health experts say ul­timately decide whether a methadone program succeeds. Some of the NGOs also feel the clin­ic has given too little thought to eventually get­ting patients off methadone, essentially just a synthetic version of heroin with a longer, mild­er high.

“Where the problems are is everything be­hind the clinical process,” said David Harding, international training coordinator for the NGO Friends International, which works with drug users in Cambodia.

“The social aspects are lagging a long, long way behind still,” he said.

One of the clinic’s aims was to show the gov­ernment a kinder, voluntary approach to treating drug addicts that works. But the state appears to have lost little enthusiasm for the centers where it locks up some 2,000 drug users against their will each year and runs them through military-style drills for a few months in the place of gen­uine treatment. According to the World Health Organization (WHO), just about everyone who goes through the centers soon relapses.

Plans to impose new user fees on the pa­tients, or the NGOs that sponsor them, could also threaten the collapse of the clinical side of the program that actually works.

Slow Start

Mr. Chan Long, one of the methadone clin­ic’s newest patients, started out taking yama—methamphetamine tablets that take their name from the Hindu god of death—in 2003 with his friends. Another group of friends put him onto heroin a few years later. To pay for his habit, he painted motorcycles.

“But it was not enough money, so I would go out and steal. It could be a motorbike, anything,” he recalled. A two-year stint in Prey Sar prison, for beating a man while trying to steal his mo­torbike, did nothing to stop his cravings. A few months at two of the government’s drug centers also did nothing to help. After each stay, he went straight back to injecting. Each attempt to quit on his own quickly failed.

His home life suffered. “My parents some­times chained me to a pole in the house or locked me in a room,” he said. None of it worked, and his parents eventually threw him out.

Living on the street, he would sometimes pick up clean needles from outreach workers for the Khmer HIV/AIDS NGO Alliance (Kha­na), one of two NGOs along with Mith Samlanh with a state license to run needle exchange pro­grams, which hand out new needles in return for used ones. But even the clean needles Mr. Chan Long would share with two other friends. He was soon diagnosed with HIV.

Down and out and sleeping rough, he finally let Khana sign him up for the methadone pro­gram a few months ago.

“It calms me down,” he said of the small cup of ruby red syrup he now drinks religiously ev­ery morning at the clinic, a small, refurbished stand-alone tucked away in a corner of the im­posing Khmer-Soviet Friendship Hospital.

“I still use heroin sometimes,” he confessed, as a drowsy expression settled on his face some­where between apathy and suspicion. “Less than before, though, so I can save some money,” he added. Since starting on methadone, he has also reconciled with his parents and moved back home.

But finding drug addicts to join the program is getting harder.

After enrolling about 100 patients in its first year, the clinic had just over 130 at the end of its second, in July. That comes to barely half of clinic director Chhit Sophal’s goal of 250.

“Our partners should work more…to refer [addicts] to the clinic,” he said.
Khana and three other organizations that work with the city’s drug users mostly blamed stepped-up police sweeps over the past two years for driving addicts deeper underground. The sweeps are part of the government’s so-called “commune and village safety plan.” In neighborhoods where outreach workers used to find dozens of users they say they’re now lucky to find two or three.

“Since 2010, the government has put the safe­ty plan in place and the police try to clean up the drug user,” taking them off the street and forcing them into the government’s drug centers, said Pin Sokhom, outreach team leader at Mith Sam­lanh. “So they hide, and it gets harder for the Mith Samlanh staff to find them.”
No one is sure just how many drug users there are in Phnom Penh, let alone those in­jecting heroin.
Government and U.N. figures on drug users nationwide vary wildly from a few hundred to 48,000. In an evaluation of the meth­adone program after its first year for AusAid, the Australian government’s international aid arm and one of the program’s key donors, Universi­ty of Adelaide professor Robert Ali said best es­timates from his sources suggested that Phnom Penh had some 1,500 inject­ing drug users, the vast ma­jority of them most likely on heroin.

The last time the govern­ment surveyed intravenous drug users, in 2007, it found one in every four of them were infected with HIV or AIDS, the highest rate of any group in the country. By con­vincing injecting heroin users to switch to methadone, the clinic was designed to bring that number down.

But Prof. Ali’s report said the program would need to reach at least 40 percent of all injecting drug users, or up to 600 people, if it hopes to make a difference.

The 131 patients enrolled at the methadone clinic as of September 30 comes nowhere near that. And with police driving potential patients deeper underground, the clinic may not get near the number any time soon.

Another Addiction

Besides bringing them patients, the metha­done program relies on the NGOs it works with to offer the social services it cannot, things like vocational training and housing assistance and reconnecting patients with estranged relatives. This way, each patient in the program essentially gets sponsored by one of those NGOs.
Mr. Harding, of Friends, said his organiza­tion sponsors 15 patients at the clinic but has grave concerns that the program has given little thought to eventually weaning patients off meth­adone. After more than two years, clinic staff say the program has yet to see a single patient suc­cessfully give up methadone.

By working like a milder, longer lasting ver­sion of heroin, methadone is supposed to give patients a chance at getting on with their lives—find work, make a home and reconnect with fam­ily. But methadone is still a drug, and still addic­tive. While patients typically progress to smaller doses, it can take them years to quit altogether. Some never do.

But in Cambodia, Mr. Harding said, “there is not a single facility, institution or program that helps them detox from methadone, which actu­ally is harder to detox from than heroin.”

He said NGOs lack their own facilities to run a safe detox program and are not licensed to administer the other medical drugs, like co­deine, often used to help the process along. The metha­done clinic has no such facil­ities, either.

“So you’re talking about a program that lends itself to continual expansion,” Mr. Harding said.
Bun Ratana, another patient at the clinic, is a case in point.

Now 28, he left home at 13 to escape an abu­sive stepfather and ended up working on a deep-sea trawler in Thailand’s notoriously abusive fishing industry, where crewmen are often fed amphetamines to help them work through gru­eling hours in slave-like conditions. Mr. Ratana started taking yama.

Returning to Phnom Penh in 2005, he joined the city’s tribe of scavengers and soon added heroin to his diet, eventually injecting up to five times a day. As he leaned forward to tell his sto­ry, his shirtsleeves drew back and the pale green flames of a fire tattoo ran up the inside of his left forearm like the teeth of an old saw. A souve­nir from the year he spent in Prey Sar prison for buying drugs, he said. As with Mr. Chan Long, though, jail did nothing to stop his cravings and upon release Mr. Ratana picked up his heroin habit just where he’d left it.

He tried adding the occasional odd job to his scavenging, he recalled, “but I could not work all day because the pain would hit me.”

Drug outreach workers for the NGO Korsang finally steered him to the methadone clinic and Mr. Ratana became one of its first patients in mid-2010. He has stopped using heroin, now has a wife and a 1-year-old son and works as a park­ing attendant.

“I don’t have to spend all that money on drugs and I can save for my kid,” he said with a ready smile on a recent morning at the clinic. “It’s a re­ally good program; it’s helped me a lot. It’s like I’m reborn.”

But asked if clinic staff had ever broached the idea of trying to take him off methadone at some point, he knitted his brow as though the thought had never even occurred to him and shook his head.

It is what the NGOs are worried about. Be­yond handing out daily doses of methadone, clin­ic staff are falling short with almost everything else. More than two years on, they say some pa­tients are still not getting their regular month­ly addiction counseling and that the counseling they do get is of poor quality.

And though the clinic keeps no running tal­ly, NGOs say more than half the methadone pa­tients—even those who have quit heroin—keep using or pick up other drugs.

“What we really need for our clients is the psycho-social part; they need [better] coun­seling,” said Taing Phoeuk, Korsang’s execu­tive director. “We try to counsel them the way we know how,” he added, but confessed that his own staff has no professional training.

Asked about the criticism of the program, Dr. Sophal smiled knowingly and sighed.
“This is our challenge…because our team don’t have much experience for that. The skill is not good enough,” he said.

Paying the Price

Dr. Sophal lays much of the blame on the on-again, off-again supply of salary supplements to his staff for fostering low morale.

Part of a nationwide program to improve the public sector, several of Cambodia’s foreign do­nors had for years been paying salary supple­ments for state employees working on donor-funded projects like the methadone clinic. By substantially boosting their modest public sal­aries, the supplements were supposed to en­courage civil servants to work full days instead of checking out early for better-paid second and third jobs in the private sector. But behind-the-scenes wrangling between donors and the gov­ernment over who should get how much period­ically derailed delivery.

Officials at the Finance Ministry have de­clined to comment on the salary supplements. But several donors confirmed that they pulled out of the program again in July after failing to agree with the government on how to keep the program going.

To keep the supplements to its staff coming, the methadone clinic came up with an “equi­ty fund” to be filled by charging the patients-—or, more likely, the NGOs sponsoring them—for service. A cup of methadone each morning, for example, would cost $2. A session with a drug counselor would cost $2.50.

Dr. Sophal reasons that methadone clinics in other countries already charge such fees and fig­ures that patients could put some of the money they spent buying drugs toward helping them­selves get well at the clinic. The most indigent would still be exempt from the fees, he added.

“If the patient decides to come,” even if they have to pay, he said, “they commit to coming; it means they are committed.”

Several donors have agreed to help cover the clinic’s fees for now. But once the NGOs hit their new fiscal year next summer, Dr. Sophal said, the burden could still shift to them.
That has both the NGOs and the WHO worried.

What works elsewhere may not work here, said Yel Daravuth, the WHO’s resident substance abuse specialist. “In the West they can afford it, but if you look to this country they do not have the money and they have to [spend it all] just for their food. So it’s going to be quite a challenge in this country,” he said, even for the NGOs.

The NGOs see a calamity coming. Korsang’s Mr. Phoeuk is especially worried. With some 90 methadone patients under its wing, his NGO sponsors the most of any. If those patients can’t pay, and Korsang can’t pay for them, there is lit­tle they will be able to done.

“For Korsang it won’t work,” he said of the user fees. “Just for dosing, take $2 times 90. We can’t afford that.”

Korsang would have to spend $65,700 a year for methadone alone, not including the follow-ups and counseling the patients need just as much. There would even be a $2 fee for a first-time consultation with every new patient the NGOs bring in.

“It’s not really been thought through,” Mr. Harding said.

If the fees do end up falling on the shoulders of the patients or the NGOs sponsoring them, he warned, “You could see a 50 percent dropout [of patients] almost immediately, and that’s not go­ing to look good for anybody.”

Should that happen, the clinic would be even further from reaching the 600 patients it needs to start bringing down HIV and AIDS infection rates among intravenous drug users, the clin­ic’s very raison d’etre. And it would make it only harder to convince the government to close down its notorious drug centers, another of the WHO’s goals.

The government calls them rehabilitation centers, though the U.N. and NGOs say they fail to do any genuine rehabilitating. The cen­ters, 10 in all, were in the spotlight in 2010 when the U.S.-based Human Rights Watch (HRW) re­leased a scathing report that drew on dozens of interviews with former detainees. It accused the facilities of not only failing to treat drug users but often subjecting them to physical and sexu­al abuse.
Government officials have repeatedly de­nied the harshest claims, but in July, HRW again called on Cambodia to close the centers down.

The National Authority for Combating Drugs (NACD) rejected the idea.

“Of course, it [the government] cannot shut down the drug rehabilitation centers,” Meas Vyrith, the NACD’s deputy secretary-general, said at the time. “Why do they just always rec­ommend closure? Do they want the drug users walking around?…. I think Human Rights Watch should build a drug center by itself to satisfy its demands.”

The methadone clinic and another volun­tary program for treating drug users, now tak­ing shape in Oddar Meanchey province’s pub­lic health clinics, are signs that attitudes toward drug addiction treatment may slowly be starting to change. But the government’s drug centers are still open. Just last month, the Social Affairs Ministry reminded Vietnam of a long-standing offer to fund the construction of what would be Cambodia’s largest government-run drug cen­ter in Preah Sihanouk province.

As Mr. Harding at Friends sees it, the gov­ernment has come to a fork in the road‑—forced treatment down one path and voluntary treat­ment down the other—and decided it had no reason to choose just one.

“There’s still the same number of centers; they’re still working the same way,” he said. “They’re basically saying ‘We’ll take both, thank you very much.’”

Dr. Sophal, who also wants to see the govern­ment abandon its drug centers, is willing to wait and let the methadone clinic speak for itself.

“It’s long term, not just one or two years,” he said.

He offered an analogy that Adam Smith, the godfather of the free market, would surely have appreciated.
“The [clinic] is a restaurant and the govern­ment [centers] are a restaurant. What kind of food do they serve? What kind of noodle? If the food is more delicious, they will come.”