Methadone treatment is proving to be the most efficient way to wean people in Bangladesh from addiction to buprenorphine, a pharmaceutical drug, and health experts say it should be expanded to reach thousands more drug users to prevent the spread of HIV. Methadone, a pain reliever, suppresses withdrawal symptoms and blocks craving.
“I think [methadone treatment] is very important for Bangladesh. It has been very well received by the beneficiaries and the success rate is good,” said Tasnim Azim, director of the HIV/AIDS Programme at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b) in the capital, Dhaka.
Buprenorphine was intended to be used to wean injecting drug users, also known as people who inject drugs (PWID), from narcotics like heroin, but has itself become a substance of addiction, with users injecting a liquid form of it.
“In Bangladesh, the buprenorphine available in the [illegal] drug market is only in the injectable form,” said Kunal Kishore, project coordinator of the drug and HIV prevention programme at the South Asian office of UN Office on Drugs and Crime (UNODC) in New Delhi, India. In countries where buprenorphine is used as medication in Opioid Substitution Therapy (OST), it is available only at approved treatment centres, and only in tablet form.
Substitution therapy is used to wean users from the substance to which they are addicted by replacing it with a substance that has similar effects, under medical supervision.
The illegal use of pharmaceutical substances, mostly buprenorphine, is on the rise in Bangladesh, but drug users are also injecting cocktails of different pharmaceuticals, according to a 2010 World Health Organization report, which also noted that sharing needles and syringes appeared “widespread” among injecting drug users, and could fuel the spread of HIV.
The country’s 2012 progress report to the UN Joint HIV/AIDS Programme (UNAIDS), said there were 23,000 injecting drug users in 2009, when HIV prevalence among those living in Dhaka, the capital, was 5 percent compared to a national rate of less than one percent.
Since 2004 more than 20,000 PWID have had access to clean needles and syringes at 120 drop-in centres across the country, but it has only been since 2008 that the National Narcotics Control Board of Bangladesh approved OST to treat addicts with daily oral doses of methadone.
The icddr, b, the Department of Narcotics Control (DNC), and the National AIDS/ STD (sexually transmitted diseases) Programme opened the first methadone maintenance treatment (MMT) clinic in Dhaka in July 2010, with support from UNODC. By 2012, attendance at the clinic had grown to 179 PWID.
The icddr’s Azim reported that 13 clients who had been unable to quit buprenorphine through “conventional detoxification and rehabilitation services” have been free from drugs for at least four months as a result of MMT.
In 2011, the government identified MMT as a “valuable component of the overall management of… dependence and the prevention of HIV among injecting drug users”.
“Previously, the DNC strongly opposed OST and it took more than a decade of advocacy to finally get permission for implementing a pilot study using methadone,” said Azim.
In 2010, there were approximately 36 million illicit opioid users worldwide, according to the most recent World Drug Report by UNODC. An opioid is a natural or synthetic narcotic that may come from opium poppies.
The UN World Health Organization (WHO) reported in 2008 that less than 10 percent of drug users globally (some 650,000) who needed substitution therapy were given it, because in many countries MMT was - and continues to be - unavailable or outlawed.
The medical use of methadone remains controversial, as over the long term some users simply substitute another addiction for the drug dependency that is being treated. Bangladesh’s 1990 Narcotics Control Act outlaws methadone, except in approved cases of medical and scientific research.
Funding by the Global Fund to Fight AIDS, Tuberculosis and Malaria will allow a second MMT clinic to open in Dhaka in the coming months, with two more to follow in the next three years. Collectively they will be able to treat a total of 600 injecting drug users.
“We are planning a phased increase in coverage, and hoping to train more people so that it will be possible to expand coverage to other cities outside Dhaka. The cost of medication is substantial, and we are advocating that methadone be produced in-country so that the cost is reduced,” said Azim.
Expanding MMT in Bangladesh will be difficult because most of the support comes from foreign donors, said Kishore. “The reduction in HIV funding by foreign donors will jeopardize HIV response and related drug treatment services that have recently been initiated in Bangladesh.”
Experts warn that drug substitution treatment alone is not sufficient to curb HIV infections among PWID. Providing clean needles and syringes, voluntary counselling and testing, antiretroviral treatment and support for those who need it are also critical.
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