Vietnam's progress in drug treatment faces fragile future

Thanh Nien News

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A drug addict inmate (R) and a singer (2nd R) sing together in front of other inmates during a music show organized by a group of local artists to mark the World Aids Day at a rehab in Hanoi November 29, 2013. Photo credit: AFP A drug addict inmate (R) and a singer (2nd R) sing together in front of other inmates during a music show organized by a group of local artists to mark the World Aids Day at a rehab in Hanoi November 29, 2013. Photo credit: AFP

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Le Thanh Tam, a 27-year-old drug addict, smashed a donation box at a ward government office in Ho Chi Minh City early last month hoping to grab cash to feed his drug habit; instead he was arrested by local militiamen.

That same month, police in neighboring Binh Duong Province arrested two drug addicts, 27 and 29-year-old men, several days after they stole between 20 and 30 ounces of jewelry during a 13-second gold shop heist.

In April, To Minh Nhat Hai, 33, stabbed his 63-year-old mother to death when she opened the door to his room to give him some fresh air. Hai refused to go to a government-run rehab center so his family signed him up for methadone treatment.

Hai had used heroin, but later turned to meth. According to his brother, Hai had been sent to a number of private rehab centers, but always went back to using.

These stories flashed across the pages of Vietnamese newspapers in quick briefs along accompanied by quotes from cops who warned of the possibility of a coming epidemic of drug-fueled violence.

The narrative ignores the impressive strides Vietnam has made in reforming its approach to drug users--a progress that, insiders warn, faces a precarious future.

Doing away with detention
A few years ago, local cops could grab a drug user and toss him into a remote drug detention center to do drab manual labor and attend moral education classes.

The addicts remained at the whim of the center managers who could arbitrarily decide to renew their detention orders for another one or two years.

Following heavy pressure from international donors, Vietnam and China both began to move toward harm reduction treatment methodologies and away from drug detention centers that focused on moral education and labor.

The United States International Development Agency (USAID) described Vietnam's system for handling drug offenders, in a 2012 brief, as proscribing either a 6-12 month period of community detoxification or a two-year incarceration in one of the country's 136 government rehabilitation centers (known as 06 Centers).

The centers were supported by contributions from the inmates' families and state funds. Criticism of the centers reached a fever pitch after media reports emerged of 06 center managers using interred drug addicts to provide free manual labor--including cashew-shelling and garment assembly.

"There is no evidence from anywhere in the world that such a system based on compulsory confinement can be successful in controlling drug use," the USAID brief stated two years ago. "Indeed relapse rates among 06 center releasees in Vietnam are very high (70-90 percent)."

The USAID brief described the centers as holding between 35,000-40,000 patients, but noted that Vietnam planned to expand methadone treatment to 80,000 patients by next year--a system the agency described as being cheaper and more effective than the centers.

Vietnamese authorities have noted marked success at methadone clinics--so much so, that the programs are full and awaiting new patients every day.

In June, a report by Cong An Thanh pho Ho Chi Minh (Ho Chi Minh City Police) newspaper cited a study compiled by the Ministry of Health noting that after two years, nearly all methadone patients continued treatment and only 15.87 percent continued using other drugs.

Only a little over one percent of program participants had committed crimes compared to roughly forty percent prior to methadone treatment, the report said. A little over two percent had committed "acts that badly affected their families and themselves" compared with roughly ninety percent before treatment, it added.

The US President's Emergency Plan for AIDS Relief (PEPFAR) has been the largest donor to date in Vietnam's efforts to fight HIV/AIDS.

Early on, the researchers identified injection drug users (as well as female sex workers and men who have sex with men) as the top three groups affected by the virus.

Researchers identified administrative detention centers proved a public health nightmare--an ideal breeding ground where drug users could share dirty needles and engage in unprotected sex.

Community-based treatment programs provided a better alternative for treating the virus and getting people away from needles and on to methadone--a cheap heroin substitute that's ingested orally and allows addicts to live relatively normal lives.

PEPFAR's methadone program began in 2008 in 2 provinces, 6 clinics, and 650 patients, according to US figures. As of the end of May 2014, the program has expanded to 31 provinces, 93 clinics, and approximately 17,000 patients.

Some surveys suggest that HIV remains present in roughly half of the injection drug users in HCMC.

When the money runs out
Despite all the good results, funding is drying up on both ends.

PEPFAR, for example, was created as an emergency measure. Now, it’s looking to transition out of the country.

"Currently, PEPFAR-supported programs in Vietnam are providing extensive technical assistance and capacity building to the Government of Vietnam and local institutions with the aim to strengthen and integrate the [methadone] program into national health systems," a spokesperson for the agency wrote.

"This assistance includes advocacy for innovative funding models to sustainably finance and procure methadone medication such as patient co-pay models."

According to local media reports, US subsidies made methadone treatment cost less than VND20000 (less than one dollar) per day. That price is expected to shoot up five-fold.

Insiders say that as much as 80 percent of the funding for methadone treatment is still being supplied by foreign donors--an unreliable source of cash given that Vietnam's HIV/AIDS epidemic pales in comparison to many African nations.

Moreover, given Vietnam's new middle-income status, many other donor nations are putting their money elsewhere.

Though the drug is relatively cheap to produce, these same insiders say that the Ministry of Health's funding for methadone treatment is being scaled back.

Given the budgetary constraints, few believe that Vietnam will hit its target for 2015.

Bringing it all back home
Officials say more addiction-related crimes have been reported this year and blamed a government decision passed last December requiring a court order for police to detain gamblers, prostitutes, drug users and others arrested for administrative violations--Vietnam's version of a misdemeanor.

The new Law on Handling Administrative Violations set off a wave of decrees designed to explain to police, who once handled these cases with relative impunity, what to do.

Decree Number 221 went into effect early this year requiring cops wishing to detain drug addicts to prepare a dossier on the individual and have the detention order approved by medical, judicial and social affairs officers before submitting it to a district court.

Police agencies have reported being confounded by the paperwork and district courts haven't sent anyone to a 06 center so far this year because, they say, they're still awaiting sentencing guidelines from higher courts.
Decree 221 expressly banned 06 centers from "doing harm to the life, health and dignity" of drug addicts or forcing them or their family to pay bribes. It also expressly prohibited them from abusing or extorting patient labor; or extending their stay beyond a court order.

In short, it aimed to put an end to problems associated with 06 centers while the government was phasing them out.

Cops freak out
Law enforcement and government officials have already expressed major concerns about a sudden emptying out of 06 Centers, which once essentially quarantined drug users from the rest of the population.

Lieutenant-Colonel Phan Van Hoan, chief officer of Ward 4 Police Unit in HCMC’s District 6, was worried that the lack of guidance (e.g. more decrees) has meant “many gamblers, petty thieves, and especially drug addicts are on the loose.”

“If this trend continues, the risk of a rise in drug-related crimes is inevitable,” he said.

During a meeting in July, Nguyen Thi Ngoc Hanh, a member of the HCMC People’s Committee – the municipal administration -- said: “if thousands [of drug addicts] are returned to the community, and none of them are sent to the [compulsory rehab] centers, then how can the local governments manage them? Can [authorities] guarantee public order?"

A police officer from the city’s Tan Binh District said the local police force have arrested dozens of meth users this year but have had to release them after slapping them with administrative fines.

The unidentified officer said most drug addicts know the authorities can no longer send them to 06 Centers, so they now shoot up and smoke on the streets with impunity.

Thanh Nien News carried a similar report, documenting a new rise in public drug use.

The families of some addicts have reportedly asked police to put their children into rehab, saying they “can't stand” having disruptive youths around, but claimed paperwork prevented them from doing anything, he said.

Tran Trung Dung, director of the HCMC social affairs department, said during a mid-year meeting of the city government that the lack of instructions has caused government agencies to be confused about how to deal with drug addicts.

“My department only received a set of instructions [this month],” Dung said. “The population of drug addicts living in the community is huge and growing.”

Dung said the number of drug addicts set to be discharged from rehab centers will only add to the problem as many of them are not guaranteed employment and are vulnerable to relapsing.

The city's 06 Centers currently house 8,600 drug patients, 4,500 of whom are expected to be discharged back into the community this year. Of the 3,200 people who had been discharged from such centers, around 1,000 have yet to find employment, he said.

Colonel Tran The Quan, deputy director of the Legislation Department at the Ministry of Public Security, said the ministry has asked the Supreme People’s Court to instruct lower courts how to decide on sending drug users to 06 Centers.

Nguyen Son, a vice-presiding judge from the supreme court, said the court is working on the instructions.

A judge from a district in the city said the HCMC People’s Court plans to hold a training on the matter this month and courts will start evaluating candidates for rehab programs this month. Users and their families have the option of volunteering for these centers or they can attend other private or non-compulsory treatments, such as methadone.

Officials in the central city of Da Nang have also voiced concern about the drug dilemma during their mid-year municipal meeting and called for instructions to simplify the new rules.

Vu Hung, director of the social affairs department of the Da Nang People’s Committee said drug crimes and drug users have both increased this year.

One rehab program in the city has only received ten voluntary patients this year and number of its patients has dropped significantly from last year to 113, Hung said, cited by Phap Luat Thanh pho Ho Chi Minh (Ho Chi Minh City Law) newspaper.

“The city should have a flexible measure to cut the procedures for sending a patient to rehab.”

Methadone in the time of methamphetamine
Police and customs officials here have provided shocking anecdotal evidence of a rapidly evolving meth problem throughout the country. These anecdotes include huge interdictions of the drug coming into and out of Vietnam and grizzly crime stories which often cite meth as the culprit.

On the streets, meth use has a far more casual air.

Many artists, party-goers and others see far less stigma in offering friends a puff of "ice" than, say, marijuana.

Back in 2012, an American academic working advising the city's methadone centers told Thanh Nien News that Vietnam was "blessed" by a rather homogenous population of heroin users, whom he described as being easier to treat (using methadone) than addict populations in other countries that consume an unpredictable cocktail of drugs.

"Treating them is like stepping on a balloon," he said of more difficult populations. "You get them off heroin, they start using coke, meth, whatever."

The pattern, according to PEPFAR, appears to hold true.

"[Vietnam's] opioid dependent individuals currently have relatively low usage patterns with methamphetamine," the agency's spokesperson said in an email. "Therefore, it is not likely that the rise of methamphetamine will have an impact on the effectiveness of methadone treatment."

As methadone's future remains uncertain, meth has emerged as a significant problem of its own.

In late 2012, the United Nations Office on Drugs and Crime included Vietnam on its list of countries where the availability and use of methamphetamine--particularly high-purity crystal meth being manufactured in Cambodia--had risen dramatically.

Last March, Thanh Nien News published a story that quoted numerous government sources as warning that propaganda campaigns against meth had failed.

“Ice use is spreading from big cities to industrial zones and rural areas,” said Major General Nguyen Anh Tuan, director of the Drug-Crime Police Department at the Ministry of Public Security.

His claim, initially published on the government's website, noted that meth was being smuggled into Vietnam from Laos and China as well as being made locally.

“Many of the people we've caught were sent to work abroad where they learned how to make methamphetamine,” he said.

The story also quoted a Hanoi police official as saying that, unlike heroin, the country lacked a treatment plan for meth users.

They weren't even on a list of drug users eligible for confinement in 06 Centers, he noted.

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