Evidence from Compulsory Centres for Drug Users in East and South East Asia

Transcription

1 Evidence from Compulsory Centres for Drug Users in East and South East Asia Background Paper prepared by UNODC RC EAP for the Regional Consultation on Compulsory Centres for Drug Users December 2010 Bangkok, Thailand 1

2 1. Background Compulsory Centres for Drug Users (CCDUs) are institutions in which people who use drugs or, in some cases, those suspected of using drugs and who do not voluntarily opt for drug treatment and rehabilitation are confined and undergo diverse interventions for various periods of time, with a consequent limitation of personal freedom. 1 Administered through either criminal or administrative law, CCDUs in East and South-East Asia are operated by a variety of institutions depending upon country, including law enforcement authorities, the judiciary, local/municipal authorities, the Ministry of Health and the Ministry of Social Affairs. There are at least 350,000 people who use drugs located in approximately 1,000 CCDUs across countries in East and South East Asia. 2 A number of these people are actually dependent on drugs and thus require access to effective drug dependence treatment. The WHO Expert Committee on Drug Dependence explains drug dependence as a state in which the individual has a need for repeated doses of the drug to feel good or to avoid feeling bad. 3 Drug dependence may also be considered a multi-factorial health disorder that often follows the course of a relapsing and remitting chronic disease Overall goals and objectives of CCDUs in selected countries in East and South-East Asia In response to a questionnaire administered by UNODC in May 2010, governments of three countries in East and South-East Asia provided the following responses: Country A To take drug users and addicts away from drug use promoting factors so that drug users and addicts can have an opportunity of not being intoxicated or under the influence of drugs and to consider living a drug-free life To maintain peacefulness and reduce disturbances in community To encourage drugs users and addicts to stop using drugs and enable them with social skills, vocational skills, and opportunities to reintegrate in the society. Country B To reduce the demand for narcotic and psychotropic drugs which will subsequently reduce the burden of supply reduction To reduce transmission of blood-borne infections among IDUs (injecting drug users) and towards others To improve existing structure of drug treatment services 1 Adapted from: United Nations Regional Task Force on Injecting Drug Use and HIV/AIDS for Asia and the Pacific. HIV/AIDS. Compulsory Drug Treatment Centres in East Asia. Briefing/Background Paper. 22 July 2009, Bangkok, Thailand. Final Draft. 22 WHO, UNAIDS, UNODC, GFATM and ANPUD. A strategy to halt and reverse the HIV epidemic among people who inject drugs in Asia and the Pacific World Health Organization WHO Expert Committee on Drug Dependence. WHO Technical Report Series 915. Thirty-third Report. World Health Organization. Geneva, UNODC and WHO, Principles of Drug Dependence Treatment. Discussion Paper. March United Nations Office on Drugs and Crime. Vienna. United Nations, New York. 2

3 Country C The overall goals and objectives of CCDUs in the country are to treat and rehabilitate drug addicts at in a control setting, so that they are free from physical and psychological dependence. As well as to reintegrate them into society as a normal and functional and productive individuals to the family, society and the nation by giving vocational skill training and other programmes. 3. Evidence on provision of evidence-based drug dependence treatment In 2009, WHO, UNODC and UNAIDS issued recommendations on the package of HIV prevention, treatment and care interventions, including opiate substitution and other drug dependence treatment, for injecting drug users. 5 By November 2010, the majority of countries and territories in East and South-East Asia that reported the injecting use of opiates, including Cambodia, China, Hong Kong Special Administrative Region, Indonesia, Malaysia, Myanmar, Thailand and Viet Nam had operational opioid substitution therapy (OST) programmes in place. The experience and evaluations of the opioid substitution treatment (OST) programmes in China 6 7, Hong Kong Special Administrative Region and Malaysia provide compelling evidence for the effectiveness of OST in: 1. Reducing criminal activity 2. Increasing employment prospects 3. Reducing opiate use 4. Reducing injecting episodes 5. Lowering the risk of HIV The mix of drug treatment services is vast and can include a range of interventions and services. 13 These can all be supplemented by a number of other alcohol or drug (AOD) 5 WHO/UNODC/UNAIDS. Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users. World Health Organisation Pang L, Hao Y, Mi G, Wang C, Luo W, Rou K, et al. Effectiveness of first eight methadone maintenance treatment clinics in China. AIDS 2007,21:S Ministry of Health of the People s Republic of China. China 2010 UNGASS Country Progress Report. In. Beijing: Ministry of Health; Lee SS, Newman R. Tribute to Peter Lee, pioneer of methadone treatment in Hong Kong. International Journal of Drug Policy 2009, 20: UNODC and UNAIDS. Methadone Treatment in Hong Kong: History, Strategy and Results. Experiences from the AIDS Response in China No. 1. September Department of Health, the Government of the Hong Kong Special Administrative Region. In UNODC and UNAIDS. Methadone Treatment in Hong Kong: History, Strategy and Results. Experiences from the AIDS Response in China No. 1. September Office of WHO Representative for Brunei Darussalam, Malaysia and Singapore. Review and evaluation of harm reduction programme in Malaysia In: WHO Commissioned Reports. Manila: World Health Organization; Yuswan F. Scaling up harm reduction services: Malaysia s experience. In: Meeting on the Development of the regional strategy for harm reduction in Asia and the pacific : Confronting HIV among people who inject drugs; Kuala Lumpur, Malaysia; 7 9 December Outreach and harm reduction programs including needle and syringe programs; Prevention and Education programs; Screening; Early and brief Interventions (particularly at general practitioner and community health 3

4 specific services such as those provided by self-funded self-help groups and may encompass special supported accommodation services (including for those with alcohol or drug acquired brain injuries) that are not usually part of the alcohol or drug core services. 4. What are some of the concerns associated with CCDU? a. Concerns regarding effectiveness While the provision of methadone maintenance treatment (MMT) in the community is expanding, responding to HIV prevention, treatment, care and support service needs of drug users living in the CCDUs remains a challenge, as reported by some governments in East and South-East Asia. Though findings from the initial phase of the MMT programme in Viet Nam as well as those from China and Hong Kong (SAR) provide strong evidence of the benefits associated with and the effectiveness of the MMT programme, there is little evidence of the effectiveness (including cost-effectiveness) of CCDU. Available data and information from analysis of the policy environment and evaluations of the cost-effectiveness of CCDUs indicate that the overall cost of rehabilitating drug users in such centres is neither efficacious, nor costeffective. 14 A number of countries have reported high relapse rates following release from the centres, ranging from 60 per cent in China to close to 100 per cent in Cambodia. 15 While no formal evaluations on the effectiveness of CCDUs in reducing return to methamphetamines have been conducted in East and South-East Asia, interviews with officials in one country indicate that approximately 20% of those released from CCDUs test positive for methamphetamine within two months of release from the centres. In another country, centre staff indicated that about 70 per cent of centre residents have been there before. level); Psychosocial interventions; Detoxification (medical and non-medical); Medication assisted treatment for opioid dependence (public and private); Self help groups (funded); Residential rehabilitation; Therapeutic communities; Post residential support/transition after care or reintegration services (possibly combined in outpatient counselling) and Specialist consultation and liaison services. 14 Gayle Martin, David Stephens, David Burrows, Uyen N.Vu, Lam T. Nguyen, Sac X.Tran, Duc T. Tran. Does compulsory rehabilitation in closed settings work in Vietnam? Presentation by Tran Tien Duc at Informal Consultation on Compulsory Centres for Drug Users organized by UNODC RC EAP and UNAIDS RST, 2-3 September 2010, Bangkok, Thailand. 15 World Health Organization. Western Pacific Region. Assessment of compulsory treatment of people who use drugs in Cambodia, China, Malaysia and Viet Nam: An application of selected human rights principles. World Health Organization World Health Organization. Western Pacific Region. Assessment of compulsory treatment of people who use drugs in Cambodia, China, Malaysia and Viet Nam: An application of selected human rights principles. World Health Organization Ibid. See also The University of Melbourne. Nossal Institute of Public Health & Open Society Institute. Detention as treatment. Detention of Methamphetamine Users in Cambodia, Laos and Thailand. Open Society Institute, The University of Melbourne. Nossal Institute of Public Health & Open Society Institute. Detention as treatment. Detention of Methamphetamine Users in Cambodia, Laos and Thailand. Open Society Institute,

5 Given the available data and information on CCDUs, questions can be raised regarding their effectiveness and value in terms of return of investment. A number of related concerns are raised below. b. Concerns regarding increased HIV risk and vulnerability Injecting drug use is one of the main factors determining the course of the HIV epidemics in East and South-East Asia. Due to the large population of people who inject drugs, even a low prevalence of HIV among IDUs translates into a large number of IDUs living with HIV or AIDS. According to reports submitted by the governments on progress made towards the implementation of the Declaration of Commitment on HIV and AIDS, despite the overall low prevalence of HIV in East and South-East Asian countries, much higher HIV prevalence has been reported among IDUs in a number of countries. Data and information on the HIV risk and vulnerability of people who use drugs, including people who inject drugs in CCDUs is scarce in East and South-East Asia. However, where data are available, HIV and Hepatitis C prevalence among people who inject drugs in CCDUs ranges from 54 per cent and 93.5 per cent, respectively. 26 Furthermore, there are reports that drug users in CCDUs who have HIV or AIDS, including persons co-infected with Hepatitis C 27 and other blood borne diseases, do not have access to treatment for these infections. At the same time, people who use drugs and who are living in CCDUs have limited access to HIV prevention commodities, notably condoms, within the centres. Thus, a large population of people who use drugs (approximately 350,000) in the CCDUs are unable to benefit from the HIV prevention interventions being implemented outside the centres. As there are reports of unprotected sex and unsafe drug use, including injecting drug use, among people living in CCDUs 28 this leads to an increased risk of HIV transmission within CCDUs. In addition to the high likelihood of relapse back into heroin or methamphetamine use, the reinitiation of other HIV risk behaviors upon release following up to two years in a centre is a 19 National AIDS Commission. Country report on the Follow up to the Declaration of Commitment On HIV/AIDS. In. Jakarta: National AIDS Commission, Republic of Indonesia; National AIDS Prevention and Alleviation Committee. UNGASS Country Progress Report: Thailand. Bangkok, National AIDS Programme. UNGASS Country Progress Report: Myanmar. In. Naypyidaw: Ministry of Health, The Government of the Union of Myanmar; National Center for HIV/AIDS, Dermatology and STD, Cambodia; Ministry of Health Malaysia. UNGASS Country Progress Report: Malaysia. In. Kuala Lumpur: AIDS/STD Section of the Disease Control Division, Ministry of Health, Malaysia; Ministry of Health. UNGASS Country Progress Report: Vietnam. In. Hanoi: Ministry of Health, Socialist Republic of Viet Nam; Ministry of Health of the People s Republic of China. China 2010 UNGASS Country Progress Report. In. Beijing: Ministry of Health; Responses to a questionnaire on compulsory centres for drug users, sent out by UNODC RCEAP to governments in May Ha Thi Thu Phan, "Hepatitis C and human immunodeficiency virus infections in injecting drug users in drug treatment centers in Vietnam" (January 1, 2009). Texas Medical Center Dissertations (via ProQuest). Paper AAI The University of Melbourne. Nossal Institute of Public Health & Open Society Institute. Detention as treatment. Detention of Methamphetamine Users in Cambodia, Laos and Thailand. Open Society Institute,

6 real possibility. 29 This in turn may increase the transmission of HIV among centre returnees and their sexual partners following release from the centre. Each year large numbers of drug users are released back to the community. In addition to the high relapse rates, there is an increased risk of drug related overdose upon release from CCDUs (because of lowered tolerance to drug following a period of abstinence) and a lack of education provided on risks upon release. 30 Fear of arrest and admission to CCDUs have been reported by at least two countries to drive people who use drugs underground and away from services, further hampering access and uptake of evidence-based HIV prevention and drug dependence treatment services at community level. Low uptake of HIV prevention, treatment and care intervention at the community further hampers universal access efforts among community based IDUs. In conclusion, given the available data and information on HIV related risk behaviours and prevalence of HIV and Hepatitis C among people residing in CCDUs, it is clear that the centres are not sound public health investment. c. Concerns regarding non-voluntary labour Recently, allegations have been made regarding non-voluntary labour, including in the recent report by United Nations Special Rapporteur, Mr. Anand Grover In his report, Mr. Grover drew attention to the right of everyone to the enjoyment of the highest attainable standard of physical and mental health argued that the approach of forced labor discriminates against people who use drugs, denying them their right to access medically appropriate health-care services and treatment and that forced labour, solitary confinement and experimental treatments administered without consent violate international human rights law and are illegitimate substitutes for evidence-based measures such as substitution therapy, psychological interventions and other forms of treatment given with full, informed consent Ministry of Health. UNGASS Country Progress Report: Vietnam. In. Hanoi: Ministry of Health, Socialist Republic of Viet Nam; Bergenstrom A, Go V, Nam LV, McClausland K, Thuoc NP, Celentano DD, Quan VM. A cross-sectional study on prevalence of non-fatal drug overdose and associated risk characteristics among out-of-treatment injecting drug users in north Vietnam. Journal of Substance Use Misuse. 2008; 43 (1): United Nations General Assembly. Right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Note by the Secretary-General. Sixty-fifth session. Item 69 (b) of the provisional agenda. Promotion and protection of human rights: human rights questions, including alternative approaches for improving the effective enjoyment of human rights and fundamental freedoms. A/65/ Cohen, J.E. and Amon, J.J. (2008). Health and Human Rights Concerns of Drug users in Detention in Guangxi Province, China. Public Library of Science Medicine, Dec 9; 5(12): e Commission on Human rights. Sixty-second session. Item 11 (a) of the provisional agenda. Civil And Political Rights, Including The Question Of Torture And Detention Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Manfred Nowak. Mission to China. Note: The Narcotic Control Law that entered into force in China in 2008 provides for paid labour inside the centres and prohibits any form of physical punishment, torture and isolation. E/CN.4/2006/6/Add March Human Rights Watch. Cambodia. Skin on the Cable. The Illegal Arrest, Arbitrary Detention and Torture of People Who Use Drugs in Cambodia. Human Rights Watch Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Sixty-fifth session Item 69 (b) of the provisional agenda. Promotion and protection of human rights: human rights questions, including alternative approaches for improving the effective enjoyment of human rights and fundamental freedoms. A/65/ August

7 It may be advisable for countries to note these concerns. The definition of forced labour by the International Labour Organisation is All work or service which is exacted from any person under the menace of any penalty and for which the said person has not offered himself voluntarily. 36 As a rule, forced labour is to be abolished 37 but, in exceptional circumstances, forced labour may be permitted only under certain strict conditions. Such exceptions would be work exacted from a person as a consequence of a conviction following a court decision and provided that the work or service is carried out under the supervision and control of a public authority, and that the person is not hired to or placed at the disposal of private individuals, companies or associations. 38 The Abolition of Forced Labour Convention, 1957, further notes that Each member of the International Labour Organisation which ratifies this Convention undertakes to suppress and not make use of any form of forced or compulsory labour 39 Allegations of forced labour, particularly in countries where drug users are detained in CCDUs without a court process, place increased pressure on the international community to respond. d. Concerns regarding informed consent There have been reports that people who use drugs have been subjects of experimental interventions, treatment without informed consent and compulsory treatment as well as mandatory HIV testing. 40 In this regard, the Special Rapporteur raised concerns regarding these interventions, along with military-type drills and physical exercises, since the effectiveness of these activities in treating drug dependence is not backed by scientific evidence. 41 Furthermore, the requirement of informed consent, including the right to refuse treatment, must be observed. The Special Rapporteur further notes that compulsory treatment also infringes the right to health since the treatment is usually provided for groups of individuals and thus disregards the need for informed case assessment and individual consent. UNODC and WHO note that: As any other medical procedure, in general conditions drug dependence treatment, be it psychosocial or pharmacological, should not be forced on patients A patient is entitled to reject treatment and choose the penal sanction instead treatment is offered as an alternative to incarceration or other penal sanctions, but 36 Forced Labour Convention 29, 1930, Article.2.1 Available at 37 Forced Labour Convention 29, 1930, Article 1: Each member of the International Labour Organisation which ratifies this Convention undertakes to suppress the use of forced or compulsory labour in all its forms within the shortest possible period. 38 International Labour Organization. Presentation at the Informal Consultation on Compulsory Centres for drug Users, organised by UNODC and UNAIDS, 2-3 September Abolition of Forced Labour Convention, 1957 (No. 105) 40 United Nations General Assembly. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Sixty-fifth session Item 69 (b) of the provisional agenda*. Promotion and protection of human rights: human rights questions, including alternative approaches for improving the effective enjoyment of human rights and fundamental freedoms. A/65/ August Ibid. 7

8 not imposed without consent Neither detention nor forced labour has been recognized by science as treatment for drug use disorders. 42 In summary, like with any other medical intervention, patients undergoing drug dependence treatment have the right to receive information about the potential benefits and risks involved in the treatment. Furthermore, free informed consent, including the right to decline, must precede the treatment. Any subsequent treatment plan must be informed by an individual clinical assessment on the severity of the drug dependence and treatment needs. e. Concerns regarding the rule of law Concerns have been raised regarding the process of admission to a CCDU. Specifically, due process concerns as well as the need for impartial proceedings which include legal representation and the right to appeal. In countries it is common for parents and community members to turn to law enforcement for help in dealing with problematic use of amphetamine type stimulants, yabaa, among family members. There have been reports from countries on instances where methamphetamine users have been arrested by police and arbitrarily detained or brought to the centre by parents, without access to legal representation at the time of arrest or confinement There have also been instances where such confinement has been carried out without affording the detainee with an opportunity for hearing or appeal of the decision, practices that are incompatible with international and national legal norms. Most CCDU systems typically lack mechanisms that would allow residents to file complaints related to arbitrary detention. Similarly, there are currently no independent mechanisms in place for the centre residents to report instances of non-voluntary labour, alleged abuse or neglect, or other grievances in countries in the region. 46 Any processes of this nature would be in contradiction to the right to due legal process and the right to liberty, and may lead to a perception that the detention of people who use drugs, and others, in CCDUs is illegal within the national law. This would clearly undermine the rule of law in that country. In conclusion, if people who use drugs (as well as others) are arbitrarily detained and admitted to CCDUs without a due legal process or the right to appeal the admission or the duration of the stay in the centre, in such cases, the admission and detention in the centre would contravene the right to liberty enshrined in UN Declaration of Human Rights. 42 UNODC and WHO, Principles of Drug Dependence Treatment. United Nations, New York, Human Rights Watch. Cambodia. Skin on the Cable. The Illegal Arrest, Arbitrary Detention and Torture of People Who Use Drugs in Cambodia. Human Rights Watch The University of Melbourne. Nossal Institute of Public Health & Open Society Institute. Detention as treatment. Detention of Methamphetamine Users in Cambodia, Laos and Thailand. Open Society Institute, The University of Melbourne. Nossal Institute of Public Health & Open Society Institute. Detention as treatment. Detention of Methamphetamine Users in Cambodia, Laos and Thailand. Open Society Institute, Richard Pearshouse (2009). Compulsory Drug Treatment in Thailand: Observations on the Narcotic Addict Rehabilitation Act B.E (2002). Toronto: Canadian HIV/AIDS Legal Network. 8

9 Conclusion 1. The international evidence on the benefits provided by a range of drug treatment services is clear and considerable. The evidence from East and South-East Asia is that, community-based OST programmes are available, such programmes result in major positive outcomes for the individuals and the communities at large. 2. The use of the out-patient approach to provide OST at community-level is also in line with the principles of drug dependence treatment, as recommended by WHO and UNODC, as the services are reachable by a maximum number of opioid dependent persons on a voluntary basis Above all, the experience from East and South-East Asia illustrates that governments can successfully make available and scale-up evidence-based drug dependence treatment for opioid and other dependent persons on an out-patient basis, without the need to compulsorily to detain people in CCDUs for treatment. 47 UNODC and WHO, Principles of Drug Dependence Treatment. Discussion Paper. March United Nations Office on Drugs and Crime. Vienna. United Nations, New York. 9