Methadone Around the World
Kingdom of Nepal
Today I witnessed another dying drug user on my local streets though it's been happening in regular basis I can never get used to it. The life of the dying drug user in my neighborhood reminded me that he could have been saved only if he had been given an option.
Drug use is a hidden subculture in Nepal. The fear of sigma and discrimination associated with drugs use, fear of police/ Maoist harassment and conviction and lack of appropriate and suitable harm reduction services for drug users has made them confine in close circles. This in turn has made them venerable to various infectious diseases like HIV and AIDS, Hepatitis C, other blood and needle borne infections and sexually transmitted infections. This situation is compounded by homelessness, vagrancy and petty crime as a result of dire poverty and lack of job opportunities throughout the Nation. The climate in the street is very difficult. These street drug users are in very poor health, very tired of their lives, hounded and beaten regularly by the police and Maoist alike, finally ostracized by the local communities. The level of HIV transmission among injecting drug users in Kathmandu is alarming - as high as 50%. Many initiatives over the last few years have targeted the development of relevant services to respond to this situation although the impact has been minimal. Currently service provision for drug users is extremely deficient. The limited number of rehabilitation programmed and the single harm reduction program are inadequate to meet the drug users' needs. To avoid further HIV transmission and enable drug users to contribute to their communities' accessible services should be deployed urgently.
History of Methadone Implementation:
Methadone was introduced in Nepal in 1995m due to lack of social support unit, other technical and psychosocial aspects the program was suddenly suspended in 1998 by the authorities of contemporary government which mismanaged and terrified the lives of many drug users who were enrolled in the program. Even after the official suspension of the Methadone program again some private clinic provided the Methadone to drug users without proper home work (sustainable criteria, policy, protocol and guidelines) and in the mean time the Methadone provider has stopped supplying Methadone to drug users who are enrolled in the program and compelled them to suffer a difficult life.
Policy Situation in Nepal:
In Nepal, the legal framework related to drug use and HIV is unclear, resulting in confusion among the bureaucracy, health care providers, and the police. Drug use is illegal in Nepal, and the government's aim is to achieve "zero drug use." However, there are no laws that specifically prohibit the use of Buprenorphine or Methadone treatment. The Ministry of Home Affair's (MoHA) main focus is on drug demand reduction. The MoHA approaches drug use primarily from a health perspective, with a focus on reducing HIV-related risks and harms. In practice, the processes of policy development and implementation for the control of illicit drug use and HIV and AIDS are entirely separate, as the former rests with the MoHA and the latter with the Ministry of Health (MoH)
Most of the service providers in the country are providing drug treatment aiming at total abstinence, providing minimum primary health care services and needle /syringe exchange and that is also in certain cities of Nepal. Till date there is only one substitution therapy program that is Buprenorphine, a pilot project catering services to 15 drug users only. The country has already recognized the need of comprehensive services to drug users including substation therapy with special focus on Methadone Maintenance Treatment (MMT). However, the recovering drug users in the country, who have been able to get out of drug using Behavior, are in a sense negating the concept of MMT program. The reason for reluctance to accept the MMT program from the part of recovering drug users is primarily because of lack of inappropriate and inadequate knowledge of advantages of the program. Moreover the failure of previous MMT program in the country has also fuelled the reluctance. After the agreement being reached between Ministry of Home Affairs, UNDP, UNODC, TU Teaching Hospital and Recovering Nepal to re-launch Methadone program in October 2007 from Teaching Hospital, Recovering Nepal felt the need for creating enabling and supporting environment by garnering common consensus from the service providers and to sensitize them in the issues of OST as well as comprehensive approach to drugs issue in our society.
The extremists or the few so called abstinent pundits who have started writing hate-mails to government, donors and we users activists. We did try to have meetings and consultation with them and most of the ex-users are convinced that this program is much needed however there are few remaining extremists who still are writing hate mails to all of us. Any ideas what should we do. We tried writing them back with scientific evidence but they are so closed minded that they blame us that we are doing it for the shake of dollars. As one of the extremist is son of Maoist parliamentarian he is using her power and influence to abort this program which is going to cost thousands and thousands lives.
11/10/07 - I am THRILLED to report that I received this message from my contact in Nepal...
Finally we did it!
The MMT program has been launched in Nepal from 30th October 2007.
Thanks to you that you provided us with moral support and guidance."
* READ MORE - "GREAT Update for Nepal!" *
How the system works in Australia...
Generally you can go to a clinic in your State except the Northern Territory (NT), they don't like mmt there and wont have a program. I do hear the NT doctors are big on handing out morphine, though doesn't make a lot of sense! The rest of the 5 states all have a MMT program. Most people can either go to their local GP, who must be a methadone prescribed GP or a clinic. I choose a private GP as I don't like the clinics... although they're really ok, nothing like I hear in USA ! *without prejudice* I have been to them before, but they're only there to stabilize you for a month and then pop you out into mainstream pharmacy's , or if you have financial feetox, you can go back to the clinics for a while till you get on top of things. Clinics dispense it free... State covered ... Until you can go back out to a pharmacy. Clinics arent full time dispensers, but the pharmacies are so you go in like any other customer to pick up your dose. If you display really bad behaviour etc we do have one pharmacy here... midnight pharmacy open 24/7.. and a lot of the bad behaviour's are sent there because they have a separate room you go into for dispensing. I went there once for a week. There were a few colourful characters there and most are using other things on top.
Most pharmacy's have behaviour rules, etc. If you miss 3 days, you may have be be reviewed again... by your doc or clinic as to why you're missing your doses? You may get put back to 2 take homes per week, and fees. Each state varies in fees. I know when I went to Sydney for a holiday it was $7.00 dollars a day vs $2.00 dollars a day here. So I won't live in Sydney anytime soon hehe! I pay $40.00 a fortnight..... IE 2weeks. I get weekly take homes, but have only gotten them the last 3 months and only 2 patients are on them in my pharmacy.....myself and someone else. Its a trial thing and both pharmacist and doc need to approve it.... via the government. I hope most people get weeklys, but it depends on them and if they are stable. I think you need to be on MMT for 10yrs or more, from memory . I think I was allowed it due to being on a low dose... less risk of diversion and stable after 10yrs on it. They're pretty funny here about high doses, the cap I think is 150mg. I've talked with PP before about that and it's because of OD rates... they're scared of people ODing. Therefore, they like to keep a lid on it.
Now As for red tape....
I've only done 1 urine and that was prior to weeklys. The last time before that was 8yrs ago... once you go into mainstream. I never even hear of urines. At the clinic you may do it when you first get started on methadone. A Lot of people do use Benzo's here and mix etc 1/2 and 1/2. I think they feel like, "oh well"... you stuff up you learn attitude! Their take homes are reduced to 2 again .... so rather then do all the urines all the time I think most people tend to seek out help. I think that's how the system thinks here..... keep them on a cap and if they stuff up..... we'll soon know about it! Then of course people with DD disorders are allowed other meds anyhow, no drama there.
I often read of the USA Methadone system and cringe about all these nurses dosing and the control they have on people. All the Red tape and urines, and think how lucky I have it. I mean, I go in once a week..... pay my 20.00 dollars...... pick up my 6 doses and leave. My Pharm is great and never has told me off , always concerned if anything. Most times if i'm having a bad time I just tell my doc... although 1/2 the time he's not sure what to do, lol. I can go to the clinic anytime, I guess... but would only be for detox or councilling since I have a private prescriber. The clinic is only 10 minutes away from where I live outside the city and is a friendly bunch. The same goes with Subutex ...you can choose which you want for long term maintanance... Methadone or Subutex and cost the same $20 a week. The only thing I do feel is that people that work should pay a little more , but it's an everyone pays the same thing... if you're on disability or working. Bascially it's a dispensing fee for the pharmacist that you're paying..... because the state gives the bottle free to the pharmacist.
We don't really have any advocates here... I think there really isnt a need for it as most problems are sorted out pretty quick and fairly. There isnt a big stigma here about it really.... You never hear of MMT on the news ever... and deaths arent that common either. So all in all I think its pretty effective system. Sure it's not perfect, but its the best we have. We arent computer pumped... it's a manual pump on a bottle. We have 2 brands to choose from... Galaxo Kline Smith, which is what I'm on and the strongest one... Clear/caramel. Then you have Bio Done which is cherry red. I didn't like that one, felt cheap to me .... and didn't hold me. There is only a handful of pharmacies with the Galaxo... mine included. I travel only 10 minutes there and back via the car once a week. They only recently brought in the Bio Done because people were injecting it and the sugar or something was making a mess of them. So for a handfull of people.....more have to suffer. However, there is 10 pharmacy's still using the Galaxo, but I guess newer people won't know once started on the Biodone! The only way you can get kicked off a program here is stealing from your pharmacy and not paying your fee's... so it's pretty simple... pay and behave and you're fine.. :) Most pharmacy's have you on probation for the first 3 months anyhow .... and then you kinda build a resume, lol. I've had a total of 4 pharmacies in 10 years and all have given me a good recommendation. Any take homes over 6 and 4 are diluted with water and the other 2 are left straight in case they go stale. For travelling.... If you travel interstate... no drama ...doc just faxes all your stuff . If it's overseas I think its more difficult... never done that.
I think I've covered it all and hope that helps you understand our system a little better!
OK, I’ll try to write a bit on the subject of being an MMT patient in Sweden. I say try because even though I know enough English to get by and make myself understood, it’s much harder to write about politics and/or for example technical English or such.. Since you have to know a “new” set of words that are, for one that hasn’t have English as one’s first language, rarely, or never, heard of. None the less, I’ll give it a try!
I’ve been thinking of how to best describe the system we have here and was thinking that I first could tell a bit about the history of MMT in Sweden and also about the regulations that here are proposed and accepted by social-care(don’t really know if that’s the name for it though) together with healthcare. But I believe that the social care is the one that finally writes the regulations that are to be followed all over our country. However that is new for this year and came with a lot of other changes, before this year MMT was a part of the Swedish healthcare only. As opposed to now also in conjunction with a branch of social-care/addictiontreatment.
Anyway, MMT has in fact a long history in Sweden, I think it goes back about 40 years or so. The thing is though, because of the massive criticism and the controversial view on MMT along with the VERY harsh regulations regarding drugs in general, MMT was never allowed to expand from being anything else than a project of study only. I believe I’ve read about that it was estimated that only 261 patients have had MMT from the mid 60’s to 1991. For several decades there were only one program in our whole country. Even though the program were lead by a well respected and very knowledgeable Dr, who’s name is Leif Gronblahd by the way and also has conducted many studies on the subject which all pointed out that MMT was indeed very succesfull , MMT was never allowed to expand and be accepted as a legitimate way of treating opiate addiction. At least not until January 2004 with the new regulations that finally accepted MMT as the powerful tool of recovery that it really is. Anyway, the one program that was run in our country the whole time from 1964 (I believe) to 2004 was one in a city named Uppsala, about 10kilometers from our Capitol Stockholm, and the name of the program is Ulleråker. Anyway, this clinic has been wellknown in whole Europe, since it’s one the oldest programs. It’s also known for it’s good results and is well appreciated by the patients since it’s not run in a punitive regimen but treats the person with respect. For example; For the first year you made regular visits to the clinic then you could choose to come there less often, only once a week if that’s what you prefer. You can get your meds from which pharmacy you like, all over the country. You were to leave non-observed UAs at random, somewhere around 12 times per year and if you didn’t live in the city anymore you could actually leave a sample with your urine to a local hospital. And, perhaps the most important thing of them all, relapses were not treated with threats of cancellation. Well, I admit that this clinic sounds like heaven…and it probably was. At least for a few….The few that had a low tolerance! Because no matter how enlightened this clinic seemed they had actually taken the “80-120mgs is all one need”-theory to their hearts.. Making it impossible for some to be successful or to even maintain in the programme! Sadly! Not to mention how few it was that ever got the chance to get on MMT during this time. It was a standing joke among opiate addicts for decades, that being admitted to MMT was to be to compared to win the lottery! An educated guess would be that 300 patients were admitted to MMT on the course of 40 years! Unbelievable!
Anyway, however the rules has changed a bit in this clinic as well now, I just don’t know how much. I know for sure that for many patients at the clinic in Ulleråker the change was quite dramatic when the regulations changed in 2004, mainly since those on Ulleråker who originated from another city, which most did, had to move to the city where they came from if that city were to open a clinic! And since most patients were very pleased with the treatment from their present clinic and also very aware of that their future clinic most likely would be run in a punitive regimen since that’s the only way to please many of the “nay-sayers” thus making it politically more easy to get to open a clinic. At least, that’s my belief. And then I’m not even mentioning anything about that the patients has to settle with less qualified treatment since the staff most likely will not be as well educated and experienced since the only place there has ever been something like the methadoneclinic in Ulleråker is in fact Ulleråker! But, nevertheless you mustn’t forget about that for many opiate addicts throughout our country this also bettered the odds for getting admitted on MMT since with this change of rules also came the acceptance of MMT as a legitimate treatment of opiate-addicts. Now, any Dr with the special knowledge in either addiction or psychology could open a clinic. And clinics were opening and still are opening all over our country, so I guess you could say that the natural reaction to the discovery of MMT was delayed with four decades or so just because of the nay-sayers.. And I think that I can say that our EXTREMELY conservative view on drugs, all drugs, prescribed as illicit, easily can be measured with your WOD. Here you can actually be sentenced to serve jailtime for only using and also have troubles getting help with pain even if you so were a cancer patient who probably would die in a year or so… Anyway, I would say that nowadays we have at least one clinic in every bigger city, but still there is nowhere near enough. Especially since almost every clinic only take about 50 to 60 Patients and we have only one clinic in every city and also the total number of patients I mention here include those on subutextreatment. I believe the total number of patients being on MMT of Subutex-Treatment right now is about 800 patients and that’s only 10% of the actual need….If being optimistic! However, at least something happens after almost 40 years of silence. Anyway, this was a bit about the history of MMT here in Sweden and also an effort to shortly describe the general attitude surrounding drugs in general and MMT in particular here in Sweden.
Mind you that I’ve only been in MMT for about 5 months though. So I can’t really say that I know it all, but I would say that I have a pretty good insight in how things seem to work here. I would say that I know much more than the next guy. Especially since here, we don’t have any NAMA or any kind of patient group. At least not that is accepted as one by anyone else than a few of the patients. Most of the clinics don’t want anything to do with our patientgroup and actually try to fight it. Tear down flyers, posters etc.. Threaten patients who try to spread the word etc.. I know, it sounds incredible! Especially since we’re the kind of country that in every other way claim to fight for human rights, democracy, freedom of speech/word/writing, protection of the weak etc…. Hypocracy(sp?) Well, I guess those basic human rights isn’t valid if you’re an addicts, huh? Anyway, this has made me, along with most, believe that the rules at my clinic is the very same ones that our government with social-care and healthcare accepted last year. I would say that is what almost everyone believes. And I believe that’s because this is generally NOT the way things are handled here. We are NOT used to authorities lying to us. To be honest, I didn’t know until just now either. I thought I would look it up before I wrote this letter. And I found some distinct differences, mostly they differ from how the clinics handles relapses. Many of the rules is up to the clinic respectively to decide, there are only a few rules mostly surrounding how to handle the drugs and who is to be admitted to MMT. Also, one thing that probably is worth mentioning is that treatment with Subutex is included here when I talk about MMT, because they fall under the same regulations and they go to the same clinics.
The federal accepted rules regarding cancellation from the program is :
2§ If patient despite every available support can’t seem to achieve the goals associated with the very reasons to attend a MMT program it should be cancelled if the patient :
-has not attended MMT for more than one week.
-relapse repeatedly to the use of illicit drugs.
-abuse alcohol to an extent that it is associated with medical risks.
-repeated manipulation of UAs.
-has been violent or has threatened any of the staff or patients, or
-is being convicted of a crime associated with narcotics of any kind.
And the rules that most clinics, and mine, seem to have adopted is roughly the same but with harsher ruler regarding relapses. The most current view on the subject of relapse is that the most effective way to make patients not relapse is to make them FEAR the consequences! First, since making it clear that a cancellation from the clinic means a 30 day taper at most and also state that certain crimes such as violence or threats of violence or manipulation with UAs means cancellation without a taper at all, I must say that they have certainly been successful in their efforts. At least with me. And I know I’m not the only one! However, not every clinic doctor seem to be fully aware of that an inadequate dose will greatly increase the risk of relapse. The generally adopted idea was that noone could need more than 120mgs so noone were let to have more than that. Signs of someone needing more were taken as nothing else then a proof of a bad patient who didn’t have any intention to comply.. So, unfortunately, not everyone get’s the same chance, just as everyone didn’t get it at Ulleråker, since their theories seem to be so full of holes. They still do learn quite a bit I would say. At least that’s what I hope they do! Anyway, some people has to this day still pay the price of some Doctor’s ignorance regarding MMT. Most Doctors has adopted the Dole/Nyswander-theory, it even says so on our bottles. That’s the only “way” we have here in Sweden. And if I’m not totally wrong here that’s where the “80 to 120mgs-is-all-one-need”-theory is originated from. Either way, that’s the general attitude among Doctors here although it seem to start changing. Thank God! Because I am one of those with a high tolerance and I would not have made it with only 120mgs, not a chance. I’ve 160mgs in a split dose, which was also “impossible” only 1½ years ago. Anyway, the regulations regarding cancellation at my clinic is; If you relapse more than once in a 6-month-period you run the risk of getting kicked out. You will have a “serious talk” with your councelor, socialworker and doctor where they will decide however you still have a future in the program. So, you could theoretically be kicked out after only 2 relapses even though I suspect it is rare. However, if you relapse 3 times I’m sure you are made to sign a contract that says your treatment is to be cancelled if you relapse one more time. And that contract is “valid” for at least another 6 months. I know of 2 guys that were kicked out after 3 times with the motivation that they suffered from additional mental disorders that were not helped by their MMT. One suffered from severe depression and the other one with panic attacks. And they were not feeling better… And one of them felt the need of having benzos, and that’s a big no-no here. In fact, even though you can ofcourse get a prescription on any drug from another Doctor, it will not be a valid one unless your MMT doctor has OK:ed it. So, if you’re caught taking any other meds than your MMT doctor has prescribed that’s considered a relapse, and with 3 observed UAs per week you will get caught! And the MMT doctor will NOT prescribe anything else then some of the antidepressants. Nothing for sleep and absolutely no benzos. It doesn’t matter if you even need them to survive, then they will taper you off methadone! That’s the harsh way they deal with this problem here! Or should I say not deal…? Also, about driving a car. Here, if you have a licence still, you’re not allowed to drive for the first 6 months. Not that the clinic would care but if you’re pulled over by police and they decide to test you, wich they do some times and nowadays methadone is one of the standards, you get a “drunken-drive” sentence and loose your licence for 2 years and no matter if you face jailtime or not you will loose your MMT as well due to you got a sentence that had anything to do with drugs. And actually, the rules regarding driving while on MMT is not quite written in stone yet.. So, I hope that the old 6 month rule will still stand, but it could also be that they change it to the 2 years that the ones that doesn’t have a licence but wants to take one has to wait for when they have gotten on MMT. So, there are pretty harsh rules surrounding MMT and a huge stigma too… But the most sad part is that almost noone realizes it since we (addicts) are so used to be treated this way. We are treated this way everywhere all the time. In fact, I didn’t realize how much stigma was attached to MMT or how incompassionate the rules of the clinic really are until I found and started to read on boards like WSM, NAMA and MA! But, better late then ever? And, I’ve been in touch with an real “old-timer” that has tried to start up a little something like your (USA) NAMA. He has been a methadone patient since the very first clinic started in Ulleråker in Uppsala and has been a patient for 25 years. Anyway, he has put up a website where everyone that is on methadone or subutex or have a friend or relative that is or just want to support our cause can join. Anyhow, I hope that over time, we can make a difference and help liberate the patients from the common stigma and unnecessary punitive rules surrounding MAT in general and MMT in particular. Well, I just couldn’t help myself.. It’s hard to stop me once you get me started, huh? I hope you can make anything out from what I’ve written here. And that you’ve gotten yourself a picture of how it’s like to be a methadone and subutex patient here in Sweden!
A friend in recovery