national drug policy and mmt programme

7/27/2019 NATIONAL DRUG POLICY AND MMT PROGRAMME

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1910 Shanghai Convention

Government took over importation & sale

Candu shops

1925 International Opium Convention Opium only for bona fide opium smokers

1943 League of Nations Investigative Commission

Opium on prescription only

1945 Ban on opium 1952 The Dangerous Drugs Ordinance

Prohibit possession, use, manufacture, sale &

importation


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1960s Change in drug use pattern younger abusers

Various ethnic races involved

wider range of drugs including synthetics

more dangerous route of administration

1970s End of Vietnam War

1975 Formation of Cabinet Committee on

Drugs Sudden increase

1970 only 711 new drug addicts detected

1982 new cases detected = 13,363


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Epidemic proportion

Main victims are younger generation

Future hope of nation

Threat to socio-economic, spiritual andculture

National integrity and security

National Security Council take over control

and prevention


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Establish Anti Narcotics Committee with Anti

Narcotics Task Force as operating arm

Initiating, coordinating and monitoring anti-

narcotic programs

Standing Committee on State Security and

District Security to carry out anti-narcotic

work

Nation Security Council Order 10 Sept 1983


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Agency Responsibility

AG Chambers Legislation

Police, Custom EnforcementKKM Control Poisons and Psychotropic

Substances, Detection and Detoxification,

Certification

Home Ministry Treatment and Rehabilitation of drugaddicts

Prisons Treatment and Rehabilitation of penal drug

addicts


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Agency Responsibility

Welfare Counselling and Training facilities

Information Information, publicityYouth and Sports Prevention, social support

Education Preventive education

Universities Epidemiological and sociological

research


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Dangerous Drugs Act 1952

Poisons Ordinance 1952

Drug Dependants (Treatment and Rehab) Act

1983Dangerous Drugs (Special Preventive

Measures) Act 1985

Dangerous Drugs (Forfeiture of Property) Act

1988


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The National Drug Policy was formulated to

create a drug free Malaysia by 2015 & to

ensure a peaceful life for the citizens as

well as to strengthen the stability andsecurity of the country


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The objectives of the National Drug Policy

is focused on eliminating demand for &

supply of drugs till Malaysia achieves:

Drug free families Drug free schools

Drug free workplaces

Drug free districts


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The National Drug Policy is implemented

through the following strategies:

Prevention

Enforcement Treatment & Rehabilitation

International Co-operation

* Treatment and rehabilitation committee was formed in

2005 chaired by Honorable Health Minister & AADK as

the secretariat


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Supply Reduction

Demand Reduction

Harm Reduction


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Counselling on aspects of drug addiction

Education on risk of communicable diseases

Testing for HIV, TB, STD

Needle exchange programmeMethadone substitution therapy

Use of condoms

Referral to further therapy PRN


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Started February 2006

Needle & syringe exchange + distribution of

condom

Community based Via outreach / drop-in centers

One for one exchange

Destruction of used needles/syringes

To prevent spread of HIV

To enable client access (entry point) to other

components of the harm reduction package


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Community based, outpatient

Proven in Australia, Hong Kong, US,

several countries in Europe, Iran &

Pakistan Reduced illicit opioid use

Criminal activity

Deaths due to OD

Reduced prevalence of HIV, HCV

Higher earnings, improved levels of employment

& social functioning, e.g. a return to

employment & education


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Recommended by WHO, UNAIDS, UN

Office on Drug & Crime (UNODC)

High rates of retention (DST is more

effective than no treatment, placebo &detox. alone in retaining drug users in

treatment & reducing heroin use)

Entry point to other services (health, HIV

testing, counselling, referral to other

agencies)


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General: Improving the health and quality of life of

persons with drug dependence throughachieving abstinence from drug consumption,

reduction in morbidity and mortality causedby or related to high risk behavioursassociated with drug consumption, andproviding access to services andopportunities to achieve the highest possible

level of physical, mental and social well-being.

WHO Policy Brief 2004: Reduction of HIV transmission through drug dependence treatment


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Specific: Reduce relapse Improve physical and mental health Reduce spread of infections among IVDU HIV and other blood borne viruses Health related issues (septicaemia,

thrombophlebitis, malnutrition, etc) Reduce death from OD

Improve psychosocial functioning/improvesocial adaptation and integration into society

Reduce criminal activities


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Informed consent

Opioid dependency (physical dependence)

Dependent >2years i.e. hardcore addicts only

Repeated past unsuccessful attempts tocontrol/cut down/stop use

> 18 years

Proof of identity

Personal ID card

Abide by program rules/regulations &

procedures


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Use < 2years

Less than 18 years old

Poly drug user (esp. other hypno-sedatives)

Abnormal LFT (3X upper limit ALT)Hypersensitivity

Acute medical/psychiatric disorders

Impairment of mental capacity.

High risk of self harm.

23rd May 2007


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Co-occurring alcohol dependence

Chronic pain.

Concomitant medical problems:

Head injury and increased intra cranial pressure. Pheochromocytoma.

Asthma and other resp. conditions.

Special risk patients- hypothyroidism

Poor compliance


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Prescription must be by registered medicaldoctor with accredited training inmanagement of DST

Methadone dispensed only by authorized

trained personnel. Dimust be In accordancewith guideline & The Dangerous DrugActspensing and storage

Treatment by Direct Observed Treatment(DOT)

Daily administration Ensure compliance

Ensure steady blood levels

Prevent withdrawal

Oral route, crystalline suspension (liquid form)


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Take away dose at discretion of prescribing

doctor

Not allowed for first 4 6 weeks except during

weekends under strict family/ guardian

supervision

Will depend on progress of client & presence of

family support

Allowed only if urinalysis is repeatedly negative

Monitoring is essential & clients have to be

followed up regularly as stipulated in

guidelines


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Maximum no. clients allowed is 20 new

patients per doctor per month

Documentation is important. A registry must

be maintained: Name, i/c and current address of patients on

DST

Dose of prescribed drug dispensed

Duration of treatment Frequency of take home doses

Results of urinalysis

Number of counseling sessions attended


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Registration of premises & prescribing

Doctors

Before registration all prescribers shall apply for

approval from National DST Accreditation Board.

Credentialing

Must be as stipulated by the National DST

Accreditation Board

Valid for three years, after which doctors should

apply for renewal

Training done through designated organizations

approved by MOH


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Facilities providing DST should be encouraged toprovide comprehensive services in addition todispensing DST

Maximum Number of Patients

Each approved doctor is allowed to treat a maximumof 50 regular patients in the first year

Total number of patients for each doctor at any onetime will not exceed the applicable number toensure quality and to provide appropriate treatment

care Any doctor, who intends to exceed the stipulated

numbers, should in principle upgrade their servicesto improve the level of care and supervision ofpatients


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No. of

patients

Doctors Nurses Counselling

aid

Counselling

team

Addiction

Medicine

specialist/

psychiatrist

Other

facilities

< 50 1 1 Part-time *1

51- 100 1 2 1 1 *1

101 200 1 2 2 1 * *2

> 200 2 2 2 1 1 Day care

facilities &

pharmacistrequired

* For government facilities (pharmacist)


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DST Registry: Electronic Database

A database shall be implemented to register all

prescribing doctors and patients.

Management of patients (refer guidelines) National Clinical Guidelines & Procedures for

Buprenorphine and Buprenorphine/Naloxone in

the treatment of Opioid Dependence

National Policy & Standard Operating

Procedures for Methadone Maintenance Therapy

National Methadone Maintenance Therapy

Guidelines


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Periodic evaluation should be done in

accordance with the guidelines

Medical Records

Record keeping should be strictly adhered to theguidelines

Opiate


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OpiateDependents

Treatmentagreement &

consent

Initial Assessment- Questionnaire- Physical exam- Blood/urine

Discharge from

programme

N

Y

Discharge from

programme

N

Appendix 1

Appendix 2

Appendix 3

Triage(Inclusion Criteria)

Register

Appendix 4

Y

A


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A

DST

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Counseling2 / 52

Evaluations andAssessment

at 12 &24/52

Appendix 5

Appendix 6

Appendix 7

Maintainance

Detox

Drug FreeAppendix 8-Summary of Visit

-Manual OTI

N

Y


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Aim

Minimize symptoms & signs of withdrawal

Withdrawal symptoms will be alleviated but not entirely

eliminated by doses less than 30mg

Minimize risks of sedation & toxicity


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Severity of dependence & level of tolerance to opioid

History of quantity, frequency and route

Corroborative history & urine testing

Signs & symptoms of opioid toxicity and withdrawal When in doubt, review the patient during withdrawals (helps

to resolve uncertainty about a safe starting dose)

Doses 20 mg for a 70kg pt can be presumed safe

Caution should be exercised for starting doses > 30mg


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Withdrawals begin to occur i.e. 3 - 4 hours after the

last dose of heroin

** Not mandatory but precautions must be taken not

to cause toxicity in patients who have no signs of

withdrawal


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Should be dosed with caution

Deaths in the first 2 weeks have been associated with

doses in the range of 25 - 100mg/day

Most occurring at doses of 40 - 60mg/day

Must be observed 3 - 4 hours after the first dose for signs

of toxicity or withdrawals

If patients experience persistent withdrawal at 4 hours, a

supplementary dose of 5mg can be considered


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During the first 2 weeks of MMT

Not oscillating between intoxication and withdrawals

Does not mean that patients will reach an optimum

maintenance dose Further dose adjustments may be required after patients have

been initially stabilized

Patients should be observed daily prior to dosing

Review at least once by the doctor in the first week

Dose increment subject to assessment by the doctor


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Assessment should include :

Withdrawal severity

Intoxication

Other drug use

Side effects

Patient perception of dose adequacy

Adherence to dosing regime


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Do not increase dose for first 3 days of treatment

Consider dose increments of 5 - 10mg every 3 days subjectto assessment

Total weekly increase should not exceed 20mg Maximum dose at end of the first week should typically be

no more than 40mg

Patients should be warned not to drive or operatemachinery during periods of dose adjustments


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Generally higher doses are required for maintenance

Individual variations in methadone metabolism

Typically effective maintenance doses are between 30 - 60

mg/day

Concurrent use of illicit opioids and continued injecting

use may indicate the need for a higher dose

Urinalysis - objective measure to monitor drug use


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When doses are missed 3 days, tolerance is

reduced

Patients are then at increased risk of overdose

when methadone is reintroduced

1 day : no change in dose

2 days : if no evidence of intoxication, give normal dose

3 days : administer half the dose (discuss with doctor)

4 days : patients must be seen by doctor, recommence at

40mg or half the dose, whichever is lower

5 days or more : regard as a new induction


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Recommended that patients remain in treatment

for at least 12 months to achieve enduring lifestyle

changes

Aim ensure withdrawal is completed in safety &

comfortDose reductions be made in consultation with

patients

Patients must be comfortable when commencing

the reduction regime Signs & symptoms of withdrawals will begin dose

falls below 20mg/day

Withdrawals peak D2 D3 after cessation of

methadone


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Reduce dose by 10 mg/week to a level of

40mg/day. Then reduce by 5mg/week

Rates of reduction should be negotiated with

patients

Dose changes should occur no more frequently than

once a week


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Violence or threat of violence against staff or other

patients

Property damage or theft from the methadone

program

Drug dealing on or near program premises

Repeated diversion of methadone to illicit use


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Reduce dose by 10 mg/week to a level of

40mg/day. Then reduce by 5mg/week

Rates of reduction should be negotiated with

patientsDose changes should occur no more

frequently than once a week


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national drug policy and mmt programme

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