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Experiences with Compulsory Drug Detention in Thailand: Evidence from the Mitsampan Community Research Project Kanna Hayashi Lianping Ti Karyn Kaplan Paisan Suwannawong Will Small Julio Montaner Evan Wood Thomas Kerr Slide 2 HIV Epidemic among Thai IDU Slide 3 Thai Drug Policy War on drugs in 2003 2,800 extrajudicial killings 50,000+ people into drug detention centres Slide 4 ` Thai Drug Policy The Narcotic Addiction Rehabilitation Act B.E. 2545 Reclassified people who use drugs as patients not criminalsReclassified people who use drugs as patients not criminals A rehabilitation centre shall be an institution for treatment under the Penal Codeand a unit of the Department of Probation, Ministry of JusticeA rehabilitation centre shall be an institution for treatment under the Penal Codeand a unit of the Department of Probation, Ministry of Justice There are now >85 drug detention centres in ThailandThere are now >85 drug detention centres in Thailand Programming based largely on military and physical exercises, religious activities, therapeutic community workProgramming based largely on military and physical exercises, religious activities, therapeutic community work Near total lack of evidence-based addiction treatmentNear total lack of evidence-based addiction treatment Slide 5 Thai Drug Policy Five Fences strategy in 2009-2010 300,000 drug users into drug treatment Photo from the Office of the Narcotics Control Board, Thailand, website: http://en.oncb.go.th/document/e1-act-D-Day2009-1.asp Kingdom's Unity for Victory over Drugs strategy in 2011 400,000 drug users into drug treatment Photo from : Mahitthirook, A., Laohong, K.-O., 2012. Phones, CDs seized at prison. Bangkok Post, May 18. Slide 6 Mitsampan Community Research Project Acollaborative research effort involving:A collaborative research effort involving: Serial cross-sectionalSerial cross-sectional mix-methods study mix-methods study 32 former/active drug users32 former/active drug users trained as peer researchers trained as peer researchers Peer researchers involved inPeer researchers involved in all stages of the project Thai AIDS Treatment Action Group Mitsampan Harm Reduction Center ChulalongkornUniversity Summer 2008, Bangkok, Thailand Slide 7 Three surveys completed by 700+ IDU in Bangkok (2008, 2009 & 2011)Three surveys completed by 700+ IDU in Bangkok (2008, 2009 & 2011) Recruitment through peer-based outreach and word-of-mouth Peer-administered interviews at the drop-in centres In-depth qualitative interviewsIn-depth qualitative interviews Project Design Slide 8 48% of IDU reported having had drugs planted on them by police 48% of IDU reported having had drugs planted on them by police Slide 9 9 Hayashi, BMC Public Health, 2013 38% reported being beaten by police Slide 10 10 Slide 11 Violence & Neglect in Compulsory Drug Detention They did not provide any therapythey just brought us into an environment that was like torture. As soon as they arrived, they just shoved us and kicked us behind bars, and then left us there without doing anythingI suffered withdrawal symptomsI couldnt sleep, couldnt eat and threw up whatever I ate. 11 Slide 12 Violence & Neglect in Compulsory Drug Detention I told them I was HIV positive and had a doctors letterThey just didnt listen. They didnt try to contact my relatives even though they knew I was sick. I needed medicine and had to see a doctorYet they just didnt care. 12 Slide 13 96% of those who had been compulsory detention had injected in the past week96% of those who had been compulsory detention had injected in the past week No differences in intensity of drug use were found between those who had and had not been in compulsory detention (p < 0.05)No differences in intensity of drug use were found between those who had and had not been in compulsory detention (p < 0.05) Slide 14 And does having been in the camp affect the way you use drugs? I think it hasnt had any impact on me. It doesnt affect me. Actually, I think for the younger peoplethey could use even more heavilyI used to be like that too. I was in prison for a long timeWhen I got out, I just released that pressure through a big hit. Things can go so wrong. People can just turn to do bad things...Just go extreme. Its a way to push back. Impacts of Compulsory Detention on Drug Use Slide 15 15 25% of participants report avoiding healthcare Slide 16 Kerr et al, IJDP, 2013 Slide 17 C OMPULSORY D RUG D ETENTION AND I NJECTION D RUG U SE C ESSATION AND R ELAPSE I N B ANGKOK, T HAILAND Nadia Fairbairn Kanna Hayashi Lianping Ti Karyn Kaplan Paisan Suwannawong Evan Wood Thomas Kerr Slide 18 RESULTS 209 (49.5%) individuals stopped injecting for greater than one year209 (49.5%) individuals stopped injecting for greater than one year 92 (21.7%) individuals stopped injecting between 3 and 12 months.92 (21.7%) individuals stopped injecting between 3 and 12 months. 18 Slide 19 Model 1 Cessation of >1 year Incarceration (AOR = 13.07, 95%CI = 6.64 25.72)Incarceration (AOR = 13.07, 95%CI = 6.64 25.72) Voluntary drug treatment enrollment (AOR = 2.75, 95%CI = 1.30 5.83)Voluntary drug treatment enrollment (AOR = 2.75, 95%CI = 1.30 5.83) Number of years since first injection (AOR = 1.07, 95% CI: 1.03 1.11)Number of years since first injection (AOR = 1.07, 95% CI: 1.03 1.11) Midazolam injection (AOR = 2.48, 95%CI = 1.23 4.98)Midazolam injection (AOR = 2.48, 95%CI = 1.23 4.98) Older age (AOR = 0.42, 95% CI: 0.21 0.83).Older age (AOR = 0.42, 95% CI: 0.21 0.83). 19 Slide 20 Model 2 Cessation of 3-12 months Incarceration (AOR = 5.47, 95%CI: 2.65 11.32)Incarceration (AOR = 5.47, 95%CI: 2.65 11.32) Compulsory drug detention exposure (AOR = 2.61, 95%CI = 1.18 5.80)Compulsory drug detention exposure (AOR = 2.61, 95%CI = 1.18 5.80) Midazolam injection (AOR = 3.80; 95%CI: 1.55 9.33)Midazolam injection (AOR = 3.80; 95%CI: 1.55 9.33) Voluntary drug treatment enrollment (AOR = 2.83, 95%CI = 1.25 6.39)Voluntary drug treatment enrollment (AOR = 2.83, 95%CI = 1.25 6.39) Methadone treatment exposure (AOR = 0.38; 95%CI: 0.17 0.86).Methadone treatment exposure (AOR = 0.38; 95%CI: 0.17 0.86). 20 Slide 21 RESULTS Self-reported reasons for injection cessation: becoming incarcerated (74.0%)becoming incarcerated (74.0%) feeling the need to take a break from drug use (60.7%)feeling the need to take a break from drug use (60.7%) entering voluntary drug treatment (13.0%)entering voluntary drug treatment (13.0%) being sent to compulsory drug detention (10.1%)being sent to compulsory drug detention (10.1%) hospitalization (9.5%).hospitalization (9.5%). 21 Slide 22 RESULTS Self-reported reasons for relapse into injecting: released from prison/compulsory detention (66.3%)released from prison/compulsory detention (66.3%) feelings of boredom (59.4%)feelings of boredom (59.4%) being exposed to triggers (55.2%)being exposed to triggers (55.2%) having some money (54.4%)having some money (54.4%) feelings of depression (40.8%)feelings of depression (40.8%) personal problems or family issues (19.9%).personal problems or family issues (19.9%). 22 Slide 23 SUMMARY & INTERPRETATION 50% of participants stopped injecting for > year and this was associated with incarceration, which likely reflects lengthy sentences for drug offences in this setting50% of participants stopped injecting for > year and this was associated with incarceration, which likely reflects lengthy sentences for drug offences in this setting Compulsory drug detention was associated with short-but not long-term cessation, as well as relapse, which likely reflects the fact that compulsory detention consists of a 45- day assessment and 4 months of detentionCompulsory drug detention was associated with short-but not long-term cessation, as well as relapse, which likely reflects the fact that compulsory detention consists of a 45- day assessment and 4 months of detention Voluntary addiction treatment appears to promoting cessation of injecting, while methadone treatment is not, which is likely due to the well-described deficiencies in Thailands methadone programVoluntary addiction treatment appears to promoting cessation of injecting, while methadone treatment is not, which is likely due to the well-described deficiencies in Thailands methadone program 23 Slide 24 CONCLUSION & IMPLICATIONS Thailands compulsory detention system appears to have failed to meet its basic objectivesThailands compulsory detention system appears to have failed to meet its basic objectives Compulsory drug detention is associated with various forms of police misconduct and violence, elevated HIV risk behaviour, interruptions in HIV treatment, and relapse into injectingCompulsory drug detention is associated with various forms of police misconduct and violence, elevated HIV risk behaviour, interruptions in HIV treatment, and relapse into injecting This system interacts with access to care by perpetuating stigma, shame and avoidance of healthcareThis system interacts with access to care by perpetuating stigma, shame and avoidance of healthcare The system of compulsory drug detention should be replaced with evidence-based harm reduction and addiction treatment programsThe system of compulsory drug detention should be replaced with evidence-based harm reduction and addiction treatment programs Slide 25 ACKNOWLEDGEMENTS The people who use drugs who participated in and supported the researchThe people who use drugs who participated in and supported the research Our community and NGO partners, including the staff of Mitsampan Center and Ozone House staffOur community and NGO partners, including the staff of Mitsampan Center and Ozone House staff The research staff at the BC Centre for Excellence in HIV/AIDSThe research staff at the BC Centre for Excellence in HIV/AIDS Research team: Kanna Hayashi, Mint Ti, Karyn Kaplan Paisan Suwwanawong, Evan Wood, Nadia Fairbairn, the Peer Researchers Team & co-investigatorsResearch team: Kanna Hayashi, Mint Ti, Karyn Kaplan Paisan Suwwanawong, Evan Wood, Nadia Fairbairn, the Peer Researchers Team & co-investigators Our funders: Open Society Foundation, Michael Smith Foundation for Health ResearchOur funders: Open Society Foundation, Michael Smith Foundation for Health Research Slide 26 Further information http:// uhri.cfenet.ubc.ca / http://www.ttag.info/