Win us to our harm

Are we winning the 'war on drugs'? "New HIV infections among drug addicts [in Indonesia] have dropped significantly in recent years," Ibu Nafsiah (National AIDS Commission secretary) is quoted as saying in an article (Indonesia's Uphill Fight Against Aids) in the Jakarta Globe. Ibu Naf partly puts this down to the success of the authorities in cracking down on heroin use, as well as the distribution of sterile needles, and increased use of methadone.

Let's start by examining the evidence for Ibu Naf's statement. The data from the MoH seems to support it.



However, we should bear in mind that less than 20% of the almost 400,000 people thought to be living with HIV in Indonesia actually know that they are infected. And reasonably reliable data is available only for the 26,483 who have been reported as diagnosed with AIDS. Can this be considered a representative sample from which we can draw accurate conclusions?

On the other hand, there is anecdotal evidence to support the statement. At a recent meeting Ibu Naf noted that outreach workers were finding it very difficult to find additional injecting drug users.  Yes, it is a 'hidden epidemic', but there has been considerable success in reaching these users in many parts of Java.

Further. we frequently hear that drug users are abandoning injected heroin. Some may indeed be migrating to methadone, although only 2548 clients are accessing this service according to the latest MoH report, More are probably using buprenorphine, which is reported to be quite freely available in many places.

But there is fear that more are probably switching to sabu (as crystal meth is known here). This may reduce the risk of HIV infection, but greatly increases the risk of an addled brain, and there is of course no effective substitution therapy for meth addicts.

So, although the evidence base may be limited, it does seem reasonable to infer less people are injecting heroin. But our ill-fated war on drugs just may be causing more collateral damage.

Babé

Supply and demand in strawberries and motor-cars

We can now access our Health Minister's statement to the recent meeting of the Commission on Narcotic Drugs. The achievements she claims are all in the field of supply and demand reduction. Among them, she lists the dubious achievement of a 'slight decline' in drug offence-related cases in 2008 after a massive 300% increase between 2003 and 2008. She does note that "in the area pf demand reduction, Indonesia's efforts focus on integrated comprehensive strategies as a continuum of care," whatever that means.

She notes that the economic cost of drug abuse in Indonesia was estimated to be US$32.9 billion in 2008, which she says in one-tenth of the value of global drug trade. I wonder how much of that goes to domestic corruption. Some time back someone estimated that the profits from drug dealing in Indonesia exceed the total budget of the police force. Plenty of room for a little 'lubrication.'

We should not be surprised that she does not mention harm reduction. At a cabinet meeting on AIDS a couple of years back, it is related that she omitted to deliver the parts of the statement prepared for her that referred to harm reduction. It transpired that she was uncomfortable to address this because she didn't know what harm reduction is.

Babé

First do no harm

There's been a lot of traffic among the chattering classes here as a result of the news that Indonesia was among 13 countries that voted against the inclusion of the words 'harm reduction' in a footnote to the draft Political Declaration from the 52nd Session of the Commission on Narcotics Drugs (CND) in Vienna. As a result, apparently harm reduction is not mentioned in the draft political declaration, not even in a footnote.

This has confused everyone, because as I noted in my recent prisons report, the policy of the Indonesian government (as usual, whoever that is?) strongly supports harm reduction. Indeed, Michel Sidibe, the new Executive Director of UNAIDS in a speech to a donor conference on harm reduction on 28th January, praised Indonesia for its support: "It is extremely heartening that countries with huge populations like Indonesia and China are seriously embracing the harm reduction challenge, at the full scale. Indonesia for example is aiming to ensure that needle and syringe exchange covers 70% of injecting drug users by 2010, up from the baseline of only 10%, and that methadone treatment reaches 30% of users." He must be feeling like the rug has been pulled out from under him!

Ibu Naf, the AIDS Commission Secretary quickly confirmed that this does not reflect a change in policy: "Don't worry. We're still working in accordance with the ruling of the Coordinating Minister of Peoples' Welfare [he's also the chair of the AIDS Commission]. We can continue to use the term, and continue, indeed increase, our efforts as laid out in the national work plan for AIDS."

But activists are wondering if they may still use the term 'harm reduction.' Of course, that raises the question why we use an English term for this. When we translated the Asia Harm Reduction Manual ten years ago, we went to great efforts to achieve a consensus on the Indonesian translation of 'harm reduction'. A very late final agreement meant we had to make many last moment changes only a couple of days before we went to the printers.

Pandu Riono notes that the Coordinating Minister's ruling clearly has not reached all those concerned, particularly in Vienna. We need to do a much better job of communicating, he says. Prof. Wirawan wondered if the Indonesian delegation in Vienna was aware of this ruling, but Ibu Naf confirmed that they knew. But she notes that the CND is primarily made up of law enforcers and diplomats. They would refer to the narcotics law, which does not mention harm reduction.

Actually they are in good company. As the international activists have only just noticed, back last November, Antonio Costa, the head of UN body concerned with drugs (and a UNAIDS co-sponsor), claimed harm reduction has been appropriated by "a vocal minority. This kind of harm reduction can prevent the spread of blood-borne diseases. But it does not solve the underlying problem, and can even perpetuate drug use."

It seems we all need to do a better job of communicating...

Babé

Blocking the drug of choice

Last month I wrote about the increasing misuse of buprenorphine in Indonesia, by drug users who grind up the tablets, mix the powder with water and inject the resulting murky mix. Thus they not only continue to spread viruses through sharing needles, but also frequently suffer health problems as a result of putting lumps of buprenorphine into their bloodstream.

Because drug users have a habit of doing things like this, in many parts of the world plain buprenorphine is no longer sold. It is only approved in a fixed-dose combination with naloxone. Naloxone is usually used alone to bring people rapidly out of a opiate-induced overdose, by taking over the receptors in the brain which are occupied by the opiate. After an injection of naloxone, people with an overdose experience a very rapid and very painful withdrawal.

But naloxone only works if injected; it has no effect if swallowed. So if you inject buprenorphine mixed with naloxone, it has no sedating effect whatsoever, since as an opiate, it is blocked by the naloxone. But if the combined tablet is taken as it should be, under the tongue, the naloxone has no effect, and the buprenorphine does its job.

Now comes news that Schering-Plough, the supplier of buprenorphine in Indonesia under the brand name Subutex (the name all the drug users use), says it has decided to withdraw this from the market. It will be replaced by Suboxone, their name for the buprenophine/naloxone combination. Usually this combination is more expensive, but they say they will not increase the price.

Will this work? Drug users are notoriously tricky, and can often find their ways round barriers. Problem is (so they tell me), they don't inject for greater effect, or to get a better high, but because it's become a habit, I guess an addiction to needles. Schering-Plough say it's pretty difficult to separate the buprenorphine from the naloxone, but no doubt someone will try. And probably other manufacturers will jump in to replace the Subutex. But I fear those currently injecting buprenorphine will find something else. Still I guess we must welcome any reduction in injecting.

Babé

Drug of choice?

While in Surabaya, I heard that heroin (putaw) is no longer the drug of choice; it has been replaced by buprenorphine/Subutex. This legal drug is now being prescribed by many doctors. Buprenorphine is a synthetic opiate which is produced in pill form and should be dissolved under the tongue. So it doesn't have to be injected, and because it's legal, it doesn't trigger crime. And because its manufactured by Good Manufacturing Practices, its quality and dose is predictable.

Good news, you'd think. But the bad news is that many users grind up the pills, dissolve the powder in water then inject it - just like they did with putaw. The experts tell us that people don't inject just to get a quicker high, but because it becomes part of the habit - part of life, I guess. So although perhaps we're reducing crime, and indeed reducing costs to users (although buprenorphine is not cheap), we're not reducing the HIV infection risk.

In addition, buprenorphine doesn't dissolve in water. So the resulting suspension contains solid particles of buprenorphine, whose size depends on the effort put into grinding it up. A user in sakaw (withdrawal) is usually not very concerned with such niceties. Result is that an increasing number are suffering abscesses and other health problems from putting lumps of buprenorphine into their blood stream.

Buprenorphine 'competes' with methadone as opiate substitution therapy. But in Indonesia, there's really no competition. Although methadone is cheaper, it is only offered in a (still) relatively small number of designated clinics, usually only open in the morning. And the staff monitor its use. Buprenorphine, on the other hand, is available in most pharmacies, and if they require a prescription, that's easy! There's a doctor on the spot. And nobody cares how you use it.

Of course, all this was eminently predictable - and predicted, among others by Dr Erwin Wijono, the founder of the Jakarta Drug Dependency Hospital in the 1970's, and thus the 'father' of drug treatment in Indonesia. One day I'll write the history of how we got here.

Babé