Evidence-based treatment of drug users needed to strengthen human rights, stem drug use, and halt the HIV epidemic

Drug policies based on ideology rather than science are fueling human rights abuses of drug users, according to a panel of experts speaking at last week’s Eighteenth International AIDS Conference which took place in Vienna, Austria.

Violations of physical and legal rights coupled with poor outcomes mar many countries' drug treatment programmes, which can include forced labour or exercise and prison-like conditions.

Asia acts as the epicentre of such mandatory programmes, in which drug users are forcibly removed from their communities and kept in centres for months or years. Currently, the continent boasts an estimated 400,000 to 500,000 detainees. Considering programmes in China and Cambodia, public health researcher Richard Pearshouse claims that these programmes have seen a “massive scale-up” in recent years.

China is home some of the highest rates of drug use the world, with five to six million of the country’s citizens considered users. Known for its now banned 'rehabilitation through labour' programmes, mandatory confinement of addicts continues to be the norm. Police have also experienced expanded powers of detention and arrest in recent years, with compulsory urinary testing and extended detention time also on the rise. According to Pearshouse, users can spend up to three years in such centres.

Pearshouse contends that the now-defunct forced labour programmes were used as a source of cheap labour under the guise of being an effective way to “re-teach” users discipline and schedule. Detained individuals often worked up to 18 hours a day, experiencing beatings if they were unable or refused to work. Such programmes are simply an “efficient and effective way to… detain… a labour force”, he said.

While Cambodia hosts much smaller mandatory drug treatment programmes and boasts shorter sentences than those of their Chinese counterparts, the country is also party to many human rights abuses. Pearshouse notes that a quarter of all individuals in the centres are children, with none seeing a judge or lawyer or given the opportunity to appeal. A quarter of individuals detained, purportedly for methamphetamine abuse, are not actually addicted, by admission of the Cambodian government. While the country does not practice forced labour, compulsory exercise is common to make users “sweat out the drugs”, Pearshouse claimed.

TM Hammet of USAID voiced similar concerns as he described the situation of detainees in Vietnam’s '06 Centres', who also experience no due process and may spend up to four years within the programme. Countrywide, 33,000 users are currently detained.

Despite these harsh conditions and forced detox, the programmes have an extraordinarily high failure rate. This type of “drug treatment is profoundly unscientific”, contends Pearshouse. As such, there is “almost a 100% relapse rate”. The Vietnamese centres also practice “little or no evidence-based substance abuse programmes”, according to Hammet. “These centres are largely a moral and punitive approach to a medical and psychosocial problem,” he said.

Both Pearshouse and Hammet consider these programmes “a challenge to human rights”. Minimal access to health care is of particular concern. While some antiretrovirals are available for HIV-positive detainees, there is limited testing and treatment within Cambodian and Chinese centres, and mandatory HIV testing within Vietnam’s. Given that roughly half of all new HIV infections in China result from drug use, and that 30% of Vietnamese IDUs are HIV-positive, scarce medical care and no harm-reduction programmes within the centres are potentially fueling the epidemic, said speakers.

The limited dissemination of legal and essential substances, as a result of ideological policies, is also of concern.

According to Diederick Lohman of Human Rights Watch, considering the accessibility of morphine and methadone within the Ukraine, “poor availability and accessibility of controlled medications is a common consequence of drug laws and policies”.

He contends that the severe penalisation of drug mishandling within the country ensures that doctors often under-prescribe morphine and methadone, which the World Health Organization considers “essential” and which are commonly required by AIDS and cancer patients.

While the UN 1961 convention on narcotic drugs outlines policies that are “not especially restrictive”, Ukraine practises extremely rigid laws, which include superfluous requirements such as four doctors required to sign every prescription and an “extremely complicated licensing system”, making it difficult and costly for medical practitioners to be able to legally prescribe some medicines.

When prescriptions are given, rather than allowing patients to self-administer as is the international norm, nurses are required to visit patients’ homes, often several times a day, to disseminate drugs. As such, many doctors will simply not prescribe morphine or methadone if patients live far from healthcare centres. This rule “is a gigantic waste of health resources, which in Ukraine are already very limited”, said Lohman, who claims that the immense number of regulations make it “almost impossible for healthcare workers to provide good care”.

While many of the most ineffective policies are relics from other political and social eras, some restrictive and non-evidence-based laws are still being enacted today. Mikhail Golichenko of the United Nations Office on Drugs and Crime, Russia, explained that in 2009 the Security Council of the Russian Federation announced that so-called “propaganda” promoting substitution therapy was now illegal. While methadone treatment was already considered illegal, the new policy ensured that anyone condoning substitution therapy was acting against the law. This “ban on harm reduction” must be challenged, said Golichenko, “because it’s unconstitutional, it’s against international law. As soon as civil society start challenging these documents, the better the situation.”

Golichenko M Law enforcement vs. health and rights: the Russian challenge. Eighteenth International AIDS Conference, Vienna, abstract MOAF0201, 2010.

Lohman D et al. Availability and accessibility of opioid medications in Ukraine. Eighteenth International AIDS Conference, Vienna, abstract MOAF0202, 2010.

Pearshouse R et al. Drug detention centers and HIV in China and Cambodia. Eighteenth International AIDS Conference, Vienna, abstract MOAF0203, 2010.

Vu Y et al. Improving the drug rehabilitation system in Vietnam: a two-track strategy. Eighteenth International AIDS Conference, Vienna, abstract MOAF0204, 2010.