Experiences with Compulsory Drug Detention in Thailand: Evidence from the Mitsampan Community Research Project Kanna Hayashi Lianping Ti Karyn Kaplan Paisan Suwannawong Will Small Julio Montaner Evan Wood Thomas Kerr

HIV Epidemic among Thai IDU

Thai Drug Policy War on drugs in ,800 extrajudicial killings 50,000+ people into drug detention centres

` Thai Drug Policy The Narcotic Addiction Rehabilitation Act B.E Reclassified people who use drugs as “patients” not “criminals”Reclassified people who use drugs as “patients” not “criminals” “A rehabilitation centre shall be an institution for treatment under the Penal Code…and a unit of the Department of Probation, Ministry of Justice”“A rehabilitation centre shall be an institution for treatment under the Penal Code…and a unit of the Department of Probation, Ministry of Justice” There are now >85 drug detention centres in ThailandThere are now >85 drug detention centres in Thailand Programming based largely on military and physical exercises, religious activities, therapeutic community workProgramming based largely on military and physical exercises, religious activities, therapeutic community work Near total lack of evidence-based addiction treatmentNear total lack of evidence-based addiction treatment

Thai Drug Policy Five Fences strategy in ,000 drug users into drug treatment Photo from the Office of the Narcotics Control Board, Thailand, website: Kingdom's Unity for Victory over Drugs strategy in ,000 drug users into drug treatment Photo from : Mahitthirook, A., Laohong, K.-O., Phones, CDs seized at prison. Bangkok Post, May 18.

Mitsampan Community Research Project Acollaborative research effort involving:A collaborative research effort involving: Serial cross-sectionalSerial cross-sectional mix-methods study mix-methods study 32 former/active drug users32 former/active drug users trained as peer researchers trained as peer researchers Peer researchers involved inPeer researchers involved in all stages of the project Thai AIDS Treatment Action Group Mitsampan Harm Reduction Center ChulalongkornUniversity Summer 2008, Bangkok, Thailand

Three surveys completed by 700+ IDU in Bangkok (2008, 2009 & 2011)Three surveys completed by 700+ IDU in Bangkok (2008, 2009 & 2011)  Recruitment through peer-based outreach and word-of-mouth  Peer-administered interviews at the drop-in centres In-depth qualitative interviewsIn-depth qualitative interviews Project Design

48% of IDU reported having had drugs planted on them by police 48% of IDU reported having had drugs planted on them by police

9 Hayashi, BMC Public Health, % reported being beaten by police

10

Violence & Neglect in Compulsory Drug Detention They did not provide any therapy…they just brought us into an environment that was like torture. As soon as they arrived, they just shoved us and kicked us behind bars, and then left us there without doing anything…I suffered withdrawal symptoms…I couldn’t sleep, couldn’t eat and threw up whatever I ate. 11

Violence & Neglect in Compulsory Drug Detention I told them I was HIV positive and had a doctor’s letter…They just didn’t listen. They didn’t try to contact my relatives even though they knew I was sick. I needed medicine and had to see a doctor…Yet they just didn’t care. 12

96% of those who had been compulsory detention had injected in the past week96% of those who had been compulsory detention had injected in the past week No differences in intensity of drug use were found between those who had and had not been in compulsory detention (p < 0.05)No differences in intensity of drug use were found between those who had and had not been in compulsory detention (p < 0.05)

And does having been in the camp affect the way you use drugs? I think it hasn’t had any impact on me. It doesn’t affect me. Actually, I think for the younger people…they could use even more heavily…I used to be like that too. I was in prison for a long time…When I got out, I just released that pressure through a big hit. Things can go so wrong. People can just turn to do bad things...Just go extreme. It’s a way to push back. Impacts of Compulsory Detention on Drug Use

15 25% of participants report avoiding healthcare

Kerr et al, IJDP, 2013

C OMPULSORY D RUG D ETENTION AND I NJECTION D RUG U SE C ESSATION AND R ELAPSE I N B ANGKOK, T HAILAND Nadia Fairbairn Kanna Hayashi Lianping Ti Karyn Kaplan Paisan Suwannawong Evan Wood Thomas Kerr

RESULTS 209 (49.5%) individuals stopped injecting for greater than one year209 (49.5%) individuals stopped injecting for greater than one year 92 (21.7%) individuals stopped injecting between 3 and 12 months.92 (21.7%) individuals stopped injecting between 3 and 12 months. 18

Model 1 – Cessation of >1 year Incarceration (AOR = 13.07, 95%CI = 6.64 – 25.72)Incarceration (AOR = 13.07, 95%CI = 6.64 – 25.72) Voluntary drug treatment enrollment (AOR = 2.75, 95%CI = 1.30 – 5.83)Voluntary drug treatment enrollment (AOR = 2.75, 95%CI = 1.30 – 5.83) Number of years since first injection (AOR = 1.07, 95% CI: 1.03 – 1.11)Number of years since first injection (AOR = 1.07, 95% CI: 1.03 – 1.11) Midazolam injection (AOR = 2.48, 95%CI = 1.23 – 4.98)Midazolam injection (AOR = 2.48, 95%CI = 1.23 – 4.98) Older age (AOR = 0.42, 95% CI: 0.21 – 0.83).Older age (AOR = 0.42, 95% CI: 0.21 – 0.83). 19

Model 2 – Cessation of 3-12 months Incarceration (AOR = 5.47, 95%CI: 2.65 – 11.32)Incarceration (AOR = 5.47, 95%CI: 2.65 – 11.32) Compulsory drug detention exposure (AOR = 2.61, 95%CI = 1.18 – 5.80)Compulsory drug detention exposure (AOR = 2.61, 95%CI = 1.18 – 5.80) Midazolam injection (AOR = 3.80; 95%CI: 1.55 – 9.33)Midazolam injection (AOR = 3.80; 95%CI: 1.55 – 9.33) Voluntary drug treatment enrollment (AOR = 2.83, 95%CI = 1.25 – 6.39)Voluntary drug treatment enrollment (AOR = 2.83, 95%CI = 1.25 – 6.39) Methadone treatment exposure (AOR = 0.38; 95%CI: 0.17 – 0.86).Methadone treatment exposure (AOR = 0.38; 95%CI: 0.17 – 0.86). 20

RESULTS Self-reported reasons for injection cessation: becoming incarcerated (74.0%)becoming incarcerated (74.0%) feeling the need to “take a break” from drug use (60.7%)feeling the need to “take a break” from drug use (60.7%) entering voluntary drug treatment (13.0%)entering voluntary drug treatment (13.0%) being sent to compulsory drug detention (10.1%)being sent to compulsory drug detention (10.1%) hospitalization (9.5%).hospitalization (9.5%). 21

RESULTS Self-reported reasons for relapse into injecting: released from prison/compulsory detention (66.3%)released from prison/compulsory detention (66.3%) feelings of boredom (59.4%)feelings of boredom (59.4%) being exposed to triggers (55.2%)being exposed to triggers (55.2%) having some money (54.4%)having some money (54.4%) feelings of depression (40.8%)feelings of depression (40.8%) personal problems or family issues (19.9%).personal problems or family issues (19.9%). 22

SUMMARY & INTERPRETATION 50% of participants stopped injecting for > year and this was associated with incarceration, which likely reflects lengthy sentences for drug offences in this setting50% of participants stopped injecting for > year and this was associated with incarceration, which likely reflects lengthy sentences for drug offences in this setting Compulsory drug detention was associated with short-but not long-term cessation, as well as relapse, which likely reflects the fact that compulsory detention consists of a 45- day assessment and 4 months of detentionCompulsory drug detention was associated with short-but not long-term cessation, as well as relapse, which likely reflects the fact that compulsory detention consists of a 45- day assessment and 4 months of detention Voluntary addiction treatment appears to promoting cessation of injecting, while methadone treatment is not, which is likely due to the well-described deficiencies in Thailand’s methadone programVoluntary addiction treatment appears to promoting cessation of injecting, while methadone treatment is not, which is likely due to the well-described deficiencies in Thailand’s methadone program 23

CONCLUSION & IMPLICATIONS Thailand’s compulsory detention system appears to have failed to meet its basic objectivesThailand’s compulsory detention system appears to have failed to meet its basic objectives Compulsory drug detention is associated with various forms of police misconduct and violence, elevated HIV risk behaviour, interruptions in HIV treatment, and relapse into injectingCompulsory drug detention is associated with various forms of police misconduct and violence, elevated HIV risk behaviour, interruptions in HIV treatment, and relapse into injecting This system interacts with access to care by perpetuating stigma, shame and avoidance of healthcareThis system interacts with access to care by perpetuating stigma, shame and avoidance of healthcare The system of compulsory drug detention should be replaced with evidence-based harm reduction and addiction treatment programsThe system of compulsory drug detention should be replaced with evidence-based harm reduction and addiction treatment programs

ACKNOWLEDGEMENTS The people who use drugs who participated in and supported the researchThe people who use drugs who participated in and supported the research Our community and NGO partners, including the staff of Mitsampan Center and Ozone House staffOur community and NGO partners, including the staff of Mitsampan Center and Ozone House staff The research staff at the BC Centre for Excellence in HIV/AIDSThe research staff at the BC Centre for Excellence in HIV/AIDS Research team: Kanna Hayashi, Mint Ti, Karyn Kaplan Paisan Suwwanawong, Evan Wood, Nadia Fairbairn, the Peer Researchers Team & co-investigatorsResearch team: Kanna Hayashi, Mint Ti, Karyn Kaplan Paisan Suwwanawong, Evan Wood, Nadia Fairbairn, the Peer Researchers Team & co-investigators Our funders: Open Society Foundation, Michael Smith Foundation for Health ResearchOur funders: Open Society Foundation, Michael Smith Foundation for Health Research

Further information uhri.cfenet.ubc.ca /