Experience of Methadone Implementation in Indonesia

Dr. Ratna Mardiati

Director

The Drug Dependence Hospital, Jakarta Indonesia

 

Overview

•      Methadone has been widely accepted as one strategy of harm reduction due to HIV/AIDS high prevalence among IDUs in Indonesia

•      Methadone program is perceived more as a HIV prevention program than as a drug treatment program

•      Methadone program implementation has been limited for a certain national period of time

 

HIV/AIDS Situation among IDUs

•      July 1999, the CDC of Indonesia documented first HIV incidence from IDU population

•      1999 – 2000: Rapid Assessment and Response in 8 big cities in Indonesia showed:

–  Heroin was the major abused drug and injecting heroin was very common

–  Participants knowledge on HIV transmission was very limited

 

HIV/AIDS Situation among IDUs (2)

•      HIV transmission through needles- IDU rising sharply since 2000.

•      HIV prevalence from IDU: 24,5-53%.

•      Estimated IDU in Indonesia 124.000 – 196.000- in the year 2000.

•      IDU contributed 44% from HIV/AIDS new cases in 2004

•      We have 312 doctors who have been trained on buprenorphine treatment, 30% have done the work, approximately :  400 patients. Mostly private doctors

HIV/AIDS Situation among IDUs (3)

•      Behavior Surveillance Survey for IDU in Jakarta, Surabaya, Manado in 2002 showed:

  - IDU age < 25 th (70 %)

  - Sharing needles 71%

  - Reusing needles 88%

  - Afraid from police arrest, not using their own needles 65%

Responses Toward the Problems

•      2001: A group of key persons in this area (government & NGOs) with support of Ausaid had visited Australia to learn about HIV prevention among IDUs

•      End of 2001: There was initiative from the above group to have collaborative action between the authority bodies of drug abuse issues and HIV/AIDS issues in order to prevent HIV transmission among IDUs

 

Responses Toward the Problems (2)

•      Mid of 2001: informal advocacy to the stakeholders by the key persons in MOH-RI , WHO Indonesia and UNAIDS about the importance of establishing Methadone Maintenance Program as one strategy to minimize the problems

•      End of 2001: Indonesian Medical Association released a conditional approval of the MMP implementation (ambiguous approval)

 

Responses Toward the Problems (3)

•      2001 – 2002: preparing the establishment of MMP:

–   Approached targeted hospitals in Jakarta & Bali

–   Advocated mental health professional association and Indonesian Medical Association to overcome pros and cons among them

–   Implemented training on methadone treatment management for the staff from the two sites à capacity building

–   Methadone procurement under WHO support

 

Responses Toward the Problems (4)

•      2001 – 2004: tremendous efforts in ensuring stakeholders (health authorities, professionals, police & judiciary, religious leaders, community leaders) by the national harm reduction core team about the necessity to implement harm reduction strategies

•      End of 2003: the MOU between National AIDS Commission and National Narcotics Board was signed

 

The Establishment MMP

•      January 2003: Jakarta clinic was set-up

–  Jakarta clinic was part of specialized hospital targeting drug users à more experienced in handling drug users

•      February 2003: Bali clinic was set-up

–  Bali clinic was part of general hospital à less experienced

Facts about the Law

•      Using drug is considered as a crime, even for possessing 1-2 pills MDMA, cannabis or heroin users

•      Carrying syringe and needle is also considered as a crime

•      Opioid as a medicine might be given to patient conditionally (in emergency room or in remote area) 

•      Opioid as a medicine might be given orally by the pharmacists (Narcotic-Act)

•      Prisons in big cities in Indonesia were dominated by drug related issues (60 – 70%) and mostly are drug user

Facts about the Budget

•      Budget for health: 2% from the Government Budget

•      Drug treatment is a part of mental health budget and the budget for mental health: 1-3% from the health budget

•      No health insurance cover drug treatment

•      There is budget allocation to support the poor to access infection related problems, but not to access drug treatment

•      Budget for health under the topic of drug abuse come to National and Provincial Narcotic Board, not under the National Health Authority

•      Turn-over rate of person in charge in the police department and narcotics board is high (provincial and national level) which hinders the collaboration with health system

Facts about Methadone Clients in RSKO, Jakarta

•      30% MMT patients get ART

•      60 % MMT patients HIV (+)

•      Most of MMT patients have passed VCT

•      10% MMT patients get TB + ART

•      90% MMT patient have Hep C

 

 

Current Methadone Clients in Indonesia

•      Currently, 300 active clients in RSKO Jakarta, 30 in PHC North Jakarta

•      300 clients in Sanglah, 30 in Kerobokan prison, Bali

•      30 in Surabaya and 20 in Bandung

 

Facts about the Clients

•      About 400 clients in private doctors in Indonesia using Buphrenorpine Maintenance Treatment (BMT)

•      50 patients in RSKO using BMT

•      2 patients in RSKO using naltrexone

•      Dosage : Methadone 60-220 mg per day or Buprenorphine 2-32 mg per day

•      Take Home Dose for Methadone is 2 days, buprenorphine 7 days, after in stabilized dose

          

 

 

HEALTH POLICIES

Encourage clients to remain in treatment longer in order:

•      To prevent HIV, Hep B & Hep C, and OI transmissions

•      To provide more opportunity to change their risk behavior by psychosocial intervention

•      To broaden clients’ experience in handling their physical, emotional and social problems

 

HEALTH POLICIES (2)

Encourage clients to remain in treatment longer in order:

•      Enhancing clients’ adherence to other necessary therapy such as ARV, TB

•      Giving sufficient time for client to achieve a healthier life style

HEALTH POLICIES (3)

Scale up substitution program treatment :

•      To recruit more clients to join the program in order to minimize the HIV transmission

•      To overcome the issue of accessibility

•      To  lessen take-home dose regime regarding shorter distance to reach clinic everyday

HEALTH POLICIES (4)

Scale up substitution program treatment :

•      To decrease dropped-out, relapse, and hospital care rate

•      To assist the development of ART, TB and other medication program among IDU

•      To decrease crime

LAW ENFORCEMENT

Support the treatment program by:

•      Understanding the problems of HIV/IDUs transmission among IDU à realizing that this problem is more medical issue than legal issue

•      Secure the safety of treatment services and environment

•      Understanding that substitution treatment is a medical treatment method where the health workers have obligation to give treatment to the patients and patients have rights to be treated

 

Additional Services in MMT

•      RSKO Clinic with support of IHPCP-Ausaid, supports methadone recipients in increasing their entrepreneurship knowledge and skills

•      Sport activities for PLHA at Sutomo Hospital Surabaya

•      Involvement of case managers to link ART sites and NGO and community

Recent Conditions

•      June 2005: President of the RI visited Methadone Clinic in Jakarta à as suggested by the National Narcotics Board à moral support

•      2005: First National Meeting on Harm Reduction Issues

•      2006: starting to expand the clinics in other cities (Surabaya and Bandung) and other health settings (Primary Health Care)

•      We have 312 doctors who have been trained on buprenorphine treatment, 30% have done the work, approximately :  400 patients. Mostly private doctors

•      2006 : Preparing MoU on HR and treatment for IDU in the closed settings à MoH - Ministry of Justice - Ministry of Internal Affair

 

 

Program Challenges

•      Up to now, the authorized bodies in Drug and Food Administration (FDA) Indonesia has not released the license of methadone distribution

•      Methadone has been obtained through special access scheme

•      Accessibility is still the main issues: charge & location

•      Uncooperative attitude from the Indonesian Psychiatric Association up to now toward maintenance treatment

Action Plan

•      Revise National Guideline of MMT based on current research result

•      Continuous advocacy to the FDA and Government Pharmaceutical Coy to give methadone distribution license as soon as possible

•      Intensive advocacy to the National AIDS Commission and the National Narcotics Board to get financial support of methadone program

•      Trying to integrate methadone budget into the annual national budget

•      Scaling-up the program to other sites and health settings to overcome accessibility issues