2016/6/25 Methadone Maintenance Therapy in Taiwan Dr. Happy Kuy-Lok Tan, M.D., MPH.,MHS 17 October 2008

Taiwan : 36,000 km2  Area: 36,000 km2  (2007) Population: 22,958,360 Per Capita GNP:US$15,676 (2008 ) Life Expectancy at birth male: 75.6 female:82.3

A global view of HIV infection 33 million people [30–36 million] living with HIV,

HIV/AIDS prevalence (%) among injecting drug users ( )

Spreading of HIV in IDU

Methadone Maintenance Therapy (MMT) Developed by Dr. Vincent Dole and Dr. Marie Nyswander in 1965 Controlled, supervised supply of narcotics in a medical sense 2 useful effects: –relief of narcotic hunger –Induction of sufficient tolerance to block the euphoric effect Effective to treat Heroin dependence

Initiated by Center of Disease, Taiwan Preparation (2004~2005) Refer to other countries’ experiences, e.g. Australia, Hong Kong Invited foreign experts to share experiences International conferences MMT Program in Taiwan

Visit Hong Kong November 1, staffs visit Hong Kong Methadone clinic

Australia Rankin Court Methadone Maintenance clinic

Invite Foreign Experts Dr. Alex Wodak

Taiwan Dr. Alex Wodak

MMT Program Pilot project in 2005 by Pilot project in 2005 by  Implemented at Taipei City (1 hospital) Taipei City (1 hospital) Taipei County (1 hospital) Taipei County (1 hospital) Taoyuan County (3 hospitals) Taoyuan County (3 hospitals) Tainan County (1 hospital) Tainan County (1 hospital)

13 The first Methadone clinic at Tao-Yuan Mental Hospital Methadone clinic

14 Drug abuse Treatment Team of TMH Set up drug abuse treatment team Devoted in drug treatment and research行政院衛生署桃園療養院 Aug, 2005Oct, 2008 Psychiatrists25 Psychiatric Nurses 18 Social workers13 Psychologist11

Drug abuse treatment Team

Treatment model of the MMT program in TMH Methadone replacement –Harm-reduction oriented –Low threshold Drug counseling, education Case Management Supportive psychotherapy Crisis intervention Job counseling 2016/6/25

Out patient service OPD:Mon, Fri AM; Mon~Thu PM Taoyuan Mental Hospital, Department Of Health Since 10 Feb 2006 Nurse Evaluation Social Worker Physician Interview CBC, BCS, EKG, CxR

Computer Software Developed by our psychiatrist, Dr. Chou 2 major parts: –Computer assisted drug dispensing Correct person, Correct dose Identification and verification Record attendance and dose Make reports automatically –Computer assisted case management Monitor the attendance rate

Computer-aided drug administration

Real-time statistics

Cases overview

Individual treatment history

Fingerprint Iris Recognition 2006/2/10~2007/11/ /12/1~ Confirm identity

Dispensing of methadone Taoyuan Mental Hospital, Department Of Health Time of operation: 7:15am – 9pm

4 case managers (psychiatric nurses) Out patient counseling Phone call to :absentees for three days Remind OPD follow up Phone call 50,511 (Feb 10,2006-July 31, 2008) Case management

Case Number in Taoyuan Mental Hospital MMT program

HIV prevalence (N=2854) 2016/6/25

HCV prevalence (N=2854) 2016/6/25

Daily attendance rate in the MMT program of TMH Max: 96.3% Min: 67.8% Average: 85.2%

Retention Rate days

Urine Test for morphine and amphetamine week

Opiate Treatment Index Multi-dimensional analysis of MMT effectiveness –Drug use behavior –Needle use and sexual behaviors –Social functions –Health condition –Psychological adaptation Reliability and validity tests

OTI Employment rate (N=110)

OTI Monthly Income and Heroin Expense (N=110) Average income of general population : NT 44,240

OTI Daily Heroin Use Frequency (N=110)

OTI subscales (N=110) Lower score better outcome

Education at Prisons :MMT –32 sessions ， 1,770 prisoners Schools : Say No to Drugs –38 sessions ， 14,093 students and teachers 。 Education in schools and jails (Sep 2005-Dec.2007)

Education on MMT July 2006-July hours essential training for MMT: 8 sessions 1,162 Psychiatric Workers and Public Health workers, staff of correctional facilities Site Visit from 22 hospitals

Newspaper : 26 articlesNewspaper : 26 articles Electric media: 3Electric media: 3 Magazines: 1Magazines: 1 Educational film:Educational film: (CDC) (CDC) Educational brochure Public Education : media

Prime Minister visited TMH and talked with an IDU media

行政院衛生署桃園療養院 Taoyuan Mental Hospital, Department Of Health Acknowledgement from the government

Winning awards

MMT Program Pilot projects in 2005 Pilot projects in 2005 Island-wide after Island-wide after counties 23 counties 68 sites 68 sites

MMT in Taiwan: Numbers of hospitals & clinics

MMT in Taiwan Case Number Cumulative treatment cases On treatment cases

Gender ratio (Dec 31, 2007)

Age Distribution

年 Annual Numbers of Newly Reported HIV Cases by Mode of Transmission (CDC, Taiwan 2008) MMT

Methadone Maintenance Therapy Worldwide (57 countries) AustraliaCanadaFrance AustriaChinaGermany AlbaniaCroatiaGreece Andorra CzechHungary BelgiumDenmarkHong Kong Bulgaria EcuadorIceland BahrainEnglandIndonesia BermudaEstoniaIran BoliviaFijiIsrael Bosnia and Herzegovina FinlandIreland

Methadone Maintenance Therapy Worldwide ItalyNamibiaSouth Africa LiechtensteinNepalSri Lanka LuxemburgNorwaySpain Lithuania PolandThailand Macedonia PortugalTaiwan MalaysiaScotland United Kingdom Malta SloveniaUnited states MexicoSweden NetherlandsSwitzerland New ZealandSlovak Republic

MMT Program in Taiwan Awareness and Preparation Awareness and Preparation  Refer to other countries’ experiences, eg. Australia, New York(U.S.), Hong Kong Action plan Action plan Start “MMT pilot projects Start “MMT pilot projects” in 1 city and 3 counties The first MMT case enrolled in Taoyuan Mental Hospital Expansion nationwide Expansion nationwide

TaiwanTaoyuan 2008VS.2007↓33%↓40% 2007VS.2006↓34%↓46% 2006VS.2005↓14%↓36%

Criminal rate TaiwanTaoyuan 2007 VS 20064% 19.7% 2006 VS % 13% Criminal rate = cases/100,000 population

MMT in Taoyuan Taoyuan Mental Hospital ( begin) 135(100%)256(57%)775(76%)1182(75%)1121(65%) Hsin Kuo Min General Hospital ( begin) 25(1.6%)223(13%) Taoyuan Armed Forces General ( begin) 112(25%)141(14%)163(10.4%)195(11%) Taoyuan Veterans Hospital ( begin) 84(18%)105(10%)172(11%)195(11%) Total

Conclusion MMT is an effective treatment for heroin abusers in Taiwan Rapid expansion of MMT in Taiwan helped to control the spread of HIV infection This successful experience can be shared to other country with similar problem