TRANSFORMATION JOURNEY OF TREATMENT AND REHABILITATION PROGRAMS IN MALAYSIA: COMPULSORY OPEN ACCESS SERVICES CURE & CARE DR. SANGEETH KAUR NATIONAL ANTI DRUGS AGENCY MINISTRY OF HOME AFFAIRS MALAYSIA

Evolving government policies towards Treatment and Rehabilitation of Drug Dependency Drugs as a social problem - Department of Social Welfare - Facility – Pusat Insaf Diri 1975 - Drug Treatment and Rehabilitation Act 1983 - Drug was issued as a security threat Ministry of Home Affairs - Facility – Pusat Serenti (One Stop Centre) - National Antidrugs Agency Act - Fasiliti – Pusat Serenti (rebranded as PUSPEN [Pusat Pemulihan Penagihan Narkotik] in 2009) -Enforcement Division was established in 2007 - Transformation of Treatment and Rehabilitation at AADK - Drug Dependency treated as a chronic relapsing disease (Patient) 1983 2004 2010 onwards

COMPARISON STATISTICS OF DRUG DEPENDENTS 2011 AND 2012 Total no of registered drug dependents since 1988 till 2012 are 345,234 individuals Category of Drug Dependents 2011 2012 DECREASE (%) New Drug Dependents 6,956 5,270 -24.24 Repeat Drug Dependents 4,238 3,745 -11.63 Total 11,194 9015 -19.50

PROFILE OF DRUG DEPENDENTS 2012 / 48.3% / 31.3% / 12% Adults, 29.85% 98 % drug dependents are male 77.4% between the ages of 18-44 91.6% use traditional drugs like heroin/ morphine/ marijuana Youth, 66.88% Teenagers, 3.29%

Treatment Scenario in Malaysia Compulsory Treatment Provided for drug dependants since 1983 Drug Rehabilitation Centers (DRC) & Supervision in the Community 22 DRCs – capacity of 7,000 residents Supervision - 55,000 estimated in the community How can N.A.D.A take care of the massive numbers in the community?

Why NADA needs to Transform? Success Rate 75% ? 50% ? 20% ? 10% ? Compulsory Treatment Reluctant & Resistant Clients Problems in the DRCs Treatment Services Programs in DRCs and those undergoing Supervision Parents, Families Stigmatized Residents – criminalized (records) Changes Impact of New drugs on Clients Need for Clinical Approach Success Rate 75% ? 50% ? 20% ? 10% ? Compulsory Treatment Reluctant & Resistant Clients Problems in the DRCs Treatment Services Programs in DRCs and those undergoing Supervision Parents, Families Stigmatized Residents – criminalized (records) Changes Impact of New drugs on Clients Need for Clinical Approach Stakeholders GTP & NKRA Concept of 1Malaysia

OBJECTIVE In response to the growing drug problem and its complexity and realizing that the existing strategies are not achieving the intended effects / targets, NADA has shifted its approach from INSTITUTIONALISED rehabilitation to an open approach, OPEN ACCESS SERVICES, by setting up THE CURE AND CARE 1 MALAYSIA CLINIC or better known as C&C 1MALAYSIA CLINIC. This is a paradigm shift for NADA to transform its treatment and rehabilitation services to all its clients in the country. 2 NADA MALAYSIA

COMPULSORY REHABILITATION OPEN ACCESS AMBULATORY VOLUNTARY CENTRES Major Developments since 2010 in terms of the extension of voluntary community based treatment COMPULSORY REHABILITATION OPEN ACCESS AMBULATORY VOLUNTARY CENTRES 19 CURE & CARE REHABILITATION CENTRES 11 CURE & CARE 1MALAYSIA CLINICS

(RAWATAN DAN PEMULIHAN) AKTA PENAGIH DADAH (RAWATAN DAN PEMULIHAN) 1983 INSTITUTION BASED COMMUNITY BASED AADK DAERAH

Treat Drug Dependents as patients Treatment and Rehabilitation Strategy Return of clients as socially funcional individuals Provide a holistic approach in treatment and rehabilitation Treat Drug Dependents as patients

Cure & Care 1 Malaysia Clinic TRANSFORMASI Cure & Care 1 Malaysia Clinic Registration Office– Sg. Besi Psychiatrist/ Medical Officers Treatment Wards

CONCEPT OPEN ACCESS SERVICES Voluntarism or Walk-in Support from parents or family Referral Outreach / Motivate No Legal Implications No Pre-conditions No stigma Private and Confidential Options for clients Community-based Program Clients as patients Any Malaysian, irrespective of age, race, gender or locality can walk in voluntarily either on their own or with his/her family members (with special preference for youths or young people) to seek treatment at the C&C Clinic. Support from parents and family members are vital in ensuring clients undergo the full course of treatment. Clients are also referred by their employers, significant others, schools or institutions of higher learning or concerned friends NADA officers and NGOs are involved in outreach programs to motivate and encourage clients to come forward voluntarily. The concepts of being non-judgmental or no pre-conditions, no legal implications and supportive of the clients motivation to change are the strengths in developing this model for the needs of the clients. Clients and their families do not face the problem of stigma when seeking treatment at the C&C Clinics as compared to the compulsory treatment centres. All records of clients are treated as private and confidential and are not revealed to the public so as to ensure the identity of clients and their families. Clients are given the options to choose either the inpatient or outpatient programs as some of them have obligations or commitment to their families.

2 1 3 PROGRAMME PROVIDED PSYCHOSOCIAL CLINICAL SERVICES VOCATIONAL TRAINING AND JOB PLACEMENT 3 Early Recovery Relapse Prevention Sosial Support Family Development Spiritual and Religious programmes Counseling Self Management Outing/Excursion Sports and Recreational Activities Medical Detoxification MAT with Methadone/Suboxone Psychiatric Management HIV/HEP/TB/STI Management Inhalan Management Alcohol and Nikotin Management Immunisation Infectious Disease Screening INH Prophylaxis Skill Training Business Job Placement

TOTAL NO OF MINI C&C : 4 CLINICS (BESUT, KINTA, MIRI & KENINGAU) Distribution Karangan 01/05/12 Kota Bharu 15/10/10 Papar 01/11/10 Bkt. Mertajam 15/10/10 Bachok 1/8/12 Kuching 15/10/10 Dengkil 07/01/13 Jerantut 01/07/11 TOTAL NO OF CURE & CARE CLINICS - 11 CLINICS Sg. Besi 01/07/10 Tampoi 15/10/10 Tampin 04/04/11 Tampin 04/04/11 TOTAL NO OF MINI C&C : 4 CLINICS (BESUT, KINTA, MIRI & KENINGAU) : INPATIENT – 479 CLIENTS : OUTPATIENT – 525 CLIENTS : OPERATIONAL SINCE – 15 NOV 2011 (TILL April 2013)

STATISTIC OF CLIENTS ACCUMULATIVE 2012 ACCUMULATIVE 2011 C&C CLINIC CAPACITY CLIENT REFERRAL & ADVOCACY TOTAL INPATIENT OUTPATIENT SG.BESI 150 135 74 7 216 KOTA BHARU 50 42 13 105 BKT MERTAJAM 40 35 51 8 94 TAMPOI 100 61 2 1 64 KUCHING 30 19 26 PAPAR 20 3 25 TAMPIN 75 54 92 111 257 JERANTUT 77 4 5 86 KARANGAN 59 159 BACHOK 15 16 31 DENGKIL 14 39 CURRENT NO ( 30 Apr 2013) 591 364 147 1102 ACCUMULATIVE JAN - APR 2013 1449 1278 2248 4975 ACCUMULATIVE 2012 5043 3854 3869 12766 ACCUMULATIVE 2011 3028 2259 4080 9367 ACCUMULATIVE 2010 666 772 117 1555 ACCUMULATIVE 2010-2013 10186 8163 10314 28663 PERCENTAGE OF INCREASE OF CLIENTS FROM 2011 TO 2012 } INPATIENT : 66% OUTPATIENT : 71 %

 DRC VS. C&C CLINIC C&C CLINIC DRUG REHAB. CENTERS Compulsory Treatment & Admission through the Law; Criminal Records; Stigma Open Access Services – Voluntary Admission; Considered as Patients Focus on medical, psychiatric & clinical treatment Treatment-based services only Treatment for opiate-based addicts; all males and separate for women Treatment for all substance abusers (opiate, ATS, inhalant) – males, females & adolescent are separated Treatment Duration – 2 years Treatment duration – 1-3 months (inpatient), 4-6 months (outpatient) Capacity for residents in DRCs – 7,350 Number of clients that accessed services at 8 C&C Clinics – 9,041 Cost of food – RM8.00 x 30 days x 12 months /person = RM 2,880 Cost of food – RM8.00 x 30 x 3 months = RM720.00 Loss of Property caused by violence, arson No incidence of violence or arson

FUN, EFFECTIVE & EASY TO IMPLEMENT APPROACH

OUTCOME RESULTS OF CLIENTS DISCHARGED FROM CURE & CARE CLINICS (2010-2012) YEAR TYPE OF SERVICE TOTAL NO OF CLIENTS DISCHARGED CLIENT STATUS ENTRY TO COMPULSORY CENTRE UNDERGO REHABILITATION IN COMMUNITY PRISON COMPLIANT NOT ABLE TO BE TRACED* 2010 Inpatient 560 3 0.54% 15 2.68% 455 81.25% 81 14.46% Outpatient 294 0.00% 5 1.70% 1 0.34% 278 94.56% 10 3.40% 2011 2590 36 1.39% 203 7.84% 27 1.04% 1819 70.23% 17.57% 1600 11 0.69% 129 8.06% 8 0.50% 959 59.94% 504 31.50% 2012 3230 49 1.52% 271 8.39% 2153 66.66% 885 27.40% 2527 24 0.95% 507 20.06% 0.20% 1367 54.10% 632 25.01% TOTAL 10,801 123 1.14% 1130 10.46% 93 0.86% 7031 65.10% 2567 23.77%

OUTCOME STUDY AT C&C CLINIC Injecting drug use 46% to 8.9% Reduced by 37.1% Confident of not using drugs in the near future 61% Clients satisfied with services 94.4% Ready to recommend the clinic to family and friends 90%

OUTCOME STUDY AT C&C CLINIC 30 days BEFORE first visit to C&C Drug use history Substance 30 days BEFORE first visit to C&C Past 30 days Heroin 67.1% 4.8% Benzos; Dormi, Clona, Valium, Xanax 12% 2.0% Syabu, Meth, Ice 13.9% 2.1% Pil Kuda 3.3% 2.2% 3 or more substances in the same day 10.8% 1.7%

OUTCOME STUDY AT C&C CLINIC Health status, needs and access In general, how satisfied are you with the medical attention you receive for your health problems (other than drug addiction) at the Cure and Care Clinic? Satisfied 69.3% Very satisfied 23.9% Not very satisfied 5.6% To standardize boxes/ tables To include Simple intro plz Objective of study, Methodlogy

OUTCOME STUDY AT C&C CLINIC Qualitative analysis: Opinions and feedback on C&C program and services. Overall, happy with the C&C concept C&C encourages voluntary and ambulatory care and rehabilitation MMT is seen as a stabilizer giving 2nd chance Programs offered by C&C were well received Good support from C&C staff, Counselors and Medical Team

OUTCOME STUDY AT C&C CLINIC METHADONE MAINTENANCE PROGRAMME 2010 2011 2012 CCSC 1024 CCRC Klinik C&C Jumlah CCSC 1380 CCRC 21 Klinik C&C 351 Jumlah 1647 CCSC 1530 CCRC 40 Klinik C&C 1735 Jumlah 3305 936 (67.8%) clients employed in 2012 compared to 543 (53%) clients in 2011. Example text

OUTCOME STUDY AT C&C CLINIC 56.3% Helped maintain jobs 42.7% Helped get into government support services 54.3% Continued education 77.6% Improved family relations 72.1% Obtained permanent homes 75.9% Prevented arrest into prisons

OUTCOME STUDY AT C&C CLINIC KAJIAN KEBERKESANAN PROGRAM KLINIK C&C OLEH UNIVERSITI MALAYA OUTCOME STUDY AT C&C CLINIC 73.8% Prevented admission into Compulsory DRCs 78.3%% Helped family or friends to get treatment and rehabilitation 76.7% Access to medical care 94.9% Very satisfied with the methadone maintenance programme 94.4% Reduced drug cravings 65.4% Obtained skill training

OUTCOME STUDY AT C&C CLINIC KAJIAN KEBERKESANAN PROGRAM KLINIK C&C KOTA BHARU CRIME HISTORY Average number of times inpatients and outpatients have been sent to prison, lock up, or PUSPEN Institution BEFORE C&C Since coming to the C&C Lock-up 3.50 0.57 Prison 1.06 PUSPEN 0.61 Mansur

OUTCOME STUDY AT C&C CLINIC KAJIAN KEBERKESANAN PROGRAM KLINIK C&C KOTA BHARU Mental Health Farrah

PENGIKTIRAFAN ANTARABANGSA Drug Issues and Priorities for Southeast Asia 24th IFNGO Conference, Kuala Lumpur Gary Lewis Regional Representative, UNODC 8 November 2011 UNODC (United Nation Office of Drug And Crime) UNAIDS WHO IDPC (International Drug Policy Consortium) Pengiktirafan daripada Negara Luar Positive example: Malaysia’s Cure and Care 1 Malaysia Clinics (Gary Lewis. Regional Representative, UNODC) Commendation by Mr. Andrew Marshall, Journalist from Al-Jazeera 28

AFTERCARE AFTERCARE SERVICES Outpatient CCSC Options for Aftercare Services after discharge from C&C Clinic : as outpatient with the same C&C Clinic or other facility; or CCSC (Cure & Care Service Centres); or CCH (Community Caring House) CCVC (Cure & Care Vocational Centre) – vocational skills training TransCC – Transitional Cure&Care facility CCSC CCH CCVC TransCC The Options for aftercare 1.Cure & Care 1Malaysia Clinic 1. Cure & Care Service Centre (CCSC) 2. Caring Community House (CCH) 3. Cure & Care Vocasional Centre (CCVC) 4. TranCC – Transitional Cure & Care facility NADA District Offices

NADA VISIONS AND TARGETS Strategy Targets Process Targets Nation’s Targets Healthier people, drug-free country Strategy Targets Scaling up of Community-based services /programs Outcome Targets Better outcome and success rate in treatment & rehabilitation Process Targets Engaging Strategic Partners and Smart Partners People Targets Capacity Building – Training for officers, partners, volunteers

STRATEGIC PLANNING FOR COMMUNITY-BASED SERVICES / PROGRAMS What are N.A.D.A’s Future Plans? By 2015 By 2015 C&C 1MALAYSIA CLINIC CCH / MOBILE UNITS CCSC

No. of Compulsory Rehab. Centers (CCRC) No. of C&C 1Malaysia Clinics STRATEGIC PLAN (2011 – 2015) 2015 C&C 1Malaysia Clinic 2015 CCSC 2015 CCH No. of Compulsory Rehab. Centers (CCRC) (4) No. of CCSC – 98 No. of CCH – 96 No. of C&C 1Malaysia Clinics (18)

THANK YOU TERIMA KASIH We Care, We Serve