Methadone substitution therapy is recognized by WHO and the UN as one of the most effective treatments for opioid dependence. Drug-dependent patients are given the opioid methadone dissolved in syrup (so that they cannot inject it) — it does not cause euphoria and does not alter consciousness, so that after taking a daily dose, a person can go to work and lead a normal life.
Thanks to this substance, even those who have been using heroin for a very long time are able to give it up without painful withdrawals, which sometimes lead to death. Until now, some states are stubbornly resisting the legalization of medical methadone, although maintenance therapy based on it has long been practiced not only in the United States and Europe, but also, for example, in Iran, China, Tanzania and Senegal.
BBgate expert consultant Werner Gunthor tells us more about how the methadone substitution program is being implemented in Islamic, Asian and African countries.
Thanks to this substance, even those who have been using heroin for a very long time are able to give it up without painful withdrawals, which sometimes lead to death. Until now, some states are stubbornly resisting the legalization of medical methadone, although maintenance therapy based on it has long been practiced not only in the United States and Europe, but also, for example, in Iran, China, Tanzania and Senegal.
BBgate expert consultant Werner Gunthor tells us more about how the methadone substitution program is being implemented in Islamic, Asian and African countries.
China: collect 100 points and get discounted methadone
The Celestial Empire had to deal with drug trafficking as far back as the Opium Wars, and when the country reopened its borders in the 1980s after 40 years of isolation, heroin arrived along with trade and tourism. The world's most dangerous drug is imported into China from the southeast through the border with Burma and from the northwest from Afghanistan, Pakistan and Tajikistan.
According to official data, there were 2.475 million drug users in China in 2013, 1.326 million (53.6%) of whom were heroin addicts. According to unofficial data, the number of drug users in the country is as high as 12 million.
In Hong Kong, a methadone maintenance program was established in 1976 with the direct involvement of Robert Newman, MD, a harm reduction ideologue and one of the pioneers of substitution therapy in the United States. Now there are 20 clinics in this city, where patients are given methadone and condoms, tested for blood-borne infections, and counseled on HIV prevention.
According to statistics, more than 70% of medical methadone users in Hong Kong are employed and lead a socially active lifestyle. HIV infection among methadone program participants is kept at 0.2-0.4% per year.
«The second wave» of the program confirmed the data obtained earlier: substitution therapy contributes to a drop in crime, drug use and a decrease in the number of new HIV infections.
The Celestial Empire had to deal with drug trafficking as far back as the Opium Wars, and when the country reopened its borders in the 1980s after 40 years of isolation, heroin arrived along with trade and tourism. The world's most dangerous drug is imported into China from the southeast through the border with Burma and from the northwest from Afghanistan, Pakistan and Tajikistan.
According to official data, there were 2.475 million drug users in China in 2013, 1.326 million (53.6%) of whom were heroin addicts. According to unofficial data, the number of drug users in the country is as high as 12 million.
In Hong Kong, a methadone maintenance program was established in 1976 with the direct involvement of Robert Newman, MD, a harm reduction ideologue and one of the pioneers of substitution therapy in the United States. Now there are 20 clinics in this city, where patients are given methadone and condoms, tested for blood-borne infections, and counseled on HIV prevention.
According to statistics, more than 70% of medical methadone users in Hong Kong are employed and lead a socially active lifestyle. HIV infection among methadone program participants is kept at 0.2-0.4% per year.
«The second wave» of the program confirmed the data obtained earlier: substitution therapy contributes to a drop in crime, drug use and a decrease in the number of new HIV infections.
In 2006, the PRC government officially approved the methadone program, and its rapid spread throughout the country began.
New substitution treatment centers were primarily established in areas of China where, according to the National Drug User Registration Service, there were more than 500 registered drug users, but could accommodate a smaller number of clients. Most often they were established within an existing medical facility, such as a hospital, voluntary detoxification center or psychosocial health center.
There are also mobile clinics: medical methadone is dispensed directly from a van to reach as many rural clients as possible.
Methadone is supplied from the USA in the form of powder, and is diluted to the required concentration in China. One daily dose costs about 1 euro for a patient. Some places use a financial reward system to incentivize clients. In case of daily, without skipping a visit, points are awarded (for example, for 100 visits 1 point is assigned). Those who have a certain number of points have the benefit of a reduction in the cost of a dose of methadone, but there is a limit — the dose cannot cost less than a certain amount. Stands with the names of the «leaders» and their scores are prominently displayed in front of the entrance.
Recently, a group of scientists from the National Center for the Control and Prevention of HIV and STDs in China published a study in the academic journal of the International Society for the Study of Addictions that analyzed the portrait of an average participant in methadone programs (male, unemployed, married, high school graduate, Han ethnic group, average age 35 years).
New substitution treatment centers were primarily established in areas of China where, according to the National Drug User Registration Service, there were more than 500 registered drug users, but could accommodate a smaller number of clients. Most often they were established within an existing medical facility, such as a hospital, voluntary detoxification center or psychosocial health center.
There are also mobile clinics: medical methadone is dispensed directly from a van to reach as many rural clients as possible.
Methadone is supplied from the USA in the form of powder, and is diluted to the required concentration in China. One daily dose costs about 1 euro for a patient. Some places use a financial reward system to incentivize clients. In case of daily, without skipping a visit, points are awarded (for example, for 100 visits 1 point is assigned). Those who have a certain number of points have the benefit of a reduction in the cost of a dose of methadone, but there is a limit — the dose cannot cost less than a certain amount. Stands with the names of the «leaders» and their scores are prominently displayed in front of the entrance.
Recently, a group of scientists from the National Center for the Control and Prevention of HIV and STDs in China published a study in the academic journal of the International Society for the Study of Addictions that analyzed the portrait of an average participant in methadone programs (male, unemployed, married, high school graduate, Han ethnic group, average age 35 years).
In 2012, The Economist published a positive report on the experience of a packaging plant in the city's Zunyi district, where workers are allowed to take their daily dose of methadone during their lunch break.
Public clinics are required to have zero tolerance for drug use during methadone treatment and to report it immediately to the authorities. It is possible to get off the blacklist only after two years of proven abstinence.
This surveillance system is a major obstacle to voluntary treatment, as police harass and intimidate blacklisted people, subjecting them to unannounced interrogations and forcing them to submit to mandatory urine tests.
Methadone treatment is also practised in India and many other Asian States: Bangladesh, Indonesia, Nepal, Thailand, Myanmar, Viet Nam and Maldives. Stigma and discrimination against drug users remain major obstacles to the spread of substitution treatment in the region. In addition, the cost of treatment for individual participants is often prohibitive.
In 2012 alone, some 235,000 people were detained in more than 1,000 compulsory drug detention centers in East and Southeast Asia. The UN has called for their closure due to human rights violations and lack of proven effectiveness.
Public clinics are required to have zero tolerance for drug use during methadone treatment and to report it immediately to the authorities. It is possible to get off the blacklist only after two years of proven abstinence.
This surveillance system is a major obstacle to voluntary treatment, as police harass and intimidate blacklisted people, subjecting them to unannounced interrogations and forcing them to submit to mandatory urine tests.
Methadone treatment is also practised in India and many other Asian States: Bangladesh, Indonesia, Nepal, Thailand, Myanmar, Viet Nam and Maldives. Stigma and discrimination against drug users remain major obstacles to the spread of substitution treatment in the region. In addition, the cost of treatment for individual participants is often prohibitive.
In 2012 alone, some 235,000 people were detained in more than 1,000 compulsory drug detention centers in East and Southeast Asia. The UN has called for their closure due to human rights violations and lack of proven effectiveness.
Islamic countries
Countries in the Islamic world are usually associated with zero tolerance for drug use and other forms of deviant behavior, but as we will see below, methadone treatment and the concept of harm reduction can be incorporated into traditional Muslim culture.
The world's first «Islamic substitution therapy» program has emerged in Malaysia. This is a conservative Islamic state with a Sharia court, a ban on marriages between Muslims and non-Muslims, and a death penalty for drug smuggling. Until the country's methadone program came into existence, drug users were sent for forced treatment in state-run rehabilitation centers for two years. They were mistreated there, and when they returned home, it led to a high number of breakdowns.
Thousands of annual cases of HIV infection through injecting drug use and encouraging research findings by scientists at the University of Malaysia, where a fee-based methadone program had been operating for some time, convinced local authorities in 2005 to allocate funding for a national substitution treatment system.
According to The New York Times, thanks to a syringe exchange program and the transition of drug addicts to methadone, the number of cases of HIV infection through non-sterile injection was almost halved by 2015, and in 2021 there were fewer cases than those contracted through unprotected sex.
Countries in the Islamic world are usually associated with zero tolerance for drug use and other forms of deviant behavior, but as we will see below, methadone treatment and the concept of harm reduction can be incorporated into traditional Muslim culture.
The world's first «Islamic substitution therapy» program has emerged in Malaysia. This is a conservative Islamic state with a Sharia court, a ban on marriages between Muslims and non-Muslims, and a death penalty for drug smuggling. Until the country's methadone program came into existence, drug users were sent for forced treatment in state-run rehabilitation centers for two years. They were mistreated there, and when they returned home, it led to a high number of breakdowns.
Thousands of annual cases of HIV infection through injecting drug use and encouraging research findings by scientists at the University of Malaysia, where a fee-based methadone program had been operating for some time, convinced local authorities in 2005 to allocate funding for a national substitution treatment system.
According to The New York Times, thanks to a syringe exchange program and the transition of drug addicts to methadone, the number of cases of HIV infection through non-sterile injection was almost halved by 2015, and in 2021 there were fewer cases than those contracted through unprotected sex.
Despite the success of these programs, the country's clinics lacked facilities available for addicts, so doctors from the University of Malaysia asked the authorities to allow mosques to be used to dispense methadone. At first, they faced strong opposition. Religious leaders argued that methadone was forbidden in Islam, but the doctors were able to explain to them that, unlike other opiates, it did not cause euphoria and was simply a medicine.
The substitution therapy program started at Kuala Lumpur's Al-Rahman Mosque in 2010, and by 2012, when The New York Times reported on it, was reaching 50 Malaysians between the ages of 18 and 60.
All patients must initially come to Al-Rahman every day and receive methadone from the pharmacists after prayer. After a few months, the patient has several consecutive urine tests, and if they show that they have not used any other drugs, they are allowed to take up to three vials of the drug with them.
The substitution therapy program started at Kuala Lumpur's Al-Rahman Mosque in 2010, and by 2012, when The New York Times reported on it, was reaching 50 Malaysians between the ages of 18 and 60.
All patients must initially come to Al-Rahman every day and receive methadone from the pharmacists after prayer. After a few months, the patient has several consecutive urine tests, and if they show that they have not used any other drugs, they are allowed to take up to three vials of the drug with them.
A 48-year-old man named Carlos, who makes a living playing musical instruments at tourist spots in Kuala Lumpur, told reporters that he joined a mosque a year ago. Before that, Carlos had been a heroin user for 30 years. When he stopped spending money to quench his addiction, he was able to save up for a small house for his family.
«I think it's really great. Christian churches help drug addicts. Muslims, too, can use mosques to help people like us» — Carlos said, referring to the substitution therapy programs that often take place right inside Protestant parishes.
In 2014, Dr. Abd Rashid, lead coordinator of the Center for Addiction Research at the University of Malaysia and creator of the substitution therapy program at Al-Rahman, published a large study with colleagues in the International Journal of Drug Policy. Abd Rashid calls his project «spiritually enhanced addiction therapy».
«The idea of using mosques and possibly places of worship of other religions to treat drug addiction is a logical consequence of the growing body of evidence pointing to the positive role of religion, spirituality, and psycho-religious approaches to the treatment of physical and mental illnesses» — the authors of the article are convinced.
Dr. Abd Rashid's method was effective: in the experimental group, after one year of substitution therapy, the rate of drug use dropped from 30.85% to 8.09%, criminal behavior from 0.19% to 0.04%, and health problems from 3.63% to 0.89%.
Abd Rashid's «spiritually enhanced therapy» has not yet been adopted by Iranian mosques, but substitution therapy is available to drug addicts in this Islamic country, where the death penalty was recently threatened for distributing illicit substances and the war against opium smugglers continues on the borders with Afghanistan and Pakistan.
Iran: what female drug users without hijabs are talking about
The Islamic Republic is often cited as an example of a traditional society, forgetting that Iran is one of the countries with the highest rate of opium addiction. According to official government data alone, 2.8 million Iranians (more than 3%) are addicted to drugs, 220,000 to 250,000 are involved in the drug trade, and about 500,000 to 700,000 go to rehabilitation clinics every year.
Opium in Iran is cheaper and often more accessible than beer. Due to cultural peculiarities, many Iranians still consider it a universal cure for various ailments, and in regions of the country where medicine is difficult to access, people substitute smoking opium for going to the doctor.
Iranian police confiscate 600-700 tons of illicit substances every year, but that is only a fraction of what enters the Islamic Republic through the eastern border. As long as opium poppies continue to be grown in the Golden Crescent, any efforts by local authorities to combat the drug epidemic are likely to resemble an attempt to dredge the sea with a sieve.
The first substitution therapy center appeared in Iran in 2003. In 2007, the first specialized drug treatment clinic for women, Persepolis, opened in Tehran.
A study by Kate Dolan, an associate professor at the National Drug and Alcohol Research Centre at the University of New South Wales in Australia, found that Iranian women rarely resort to therapy because they suffer from the stigma of drug use even more than men. As a consequence, little is known about Iranian female drug users by researchers, and the country needs more women-only rehabilitation centers.
After six months of substitution therapy, compulsive desire to take opiates was observed in 27.5% of Dolan's patients rather than 85%, and withdrawal syndrome in 15% rather than 82.5%. If at the beginning of the study 15% of the patients had unprotected sex for money (and 10% — in exchange for drugs), by the end of the study these figures had dropped to zero. 42.5% (20% before therapy) of the girls started always using a condom, even during sex with a regular partner.
Dolan recently published a book, «Addiction Recovery in Tehran: A Women's Clinic» which chronicles the lives of four of her patients.
By 2017, 2,000 substitution therapy clinics existed in Tehran alone and 8,000 across the country. They offer primary health check-ups, HIV tests, antiretroviral therapy, and help with hepatitis and tuberculosis treatment.
A study by Kate Dolan, an associate professor at the National Drug and Alcohol Research Centre at the University of New South Wales in Australia, found that Iranian women rarely resort to therapy because they suffer from the stigma of drug use even more than men. As a consequence, little is known about Iranian female drug users by researchers, and the country needs more women-only rehabilitation centers.
After six months of substitution therapy, compulsive desire to take opiates was observed in 27.5% of Dolan's patients rather than 85%, and withdrawal syndrome in 15% rather than 82.5%. If at the beginning of the study 15% of the patients had unprotected sex for money (and 10% — in exchange for drugs), by the end of the study these figures had dropped to zero. 42.5% (20% before therapy) of the girls started always using a condom, even during sex with a regular partner.
Dolan recently published a book, «Addiction Recovery in Tehran: A Women's Clinic» which chronicles the lives of four of her patients.
By 2017, 2,000 substitution therapy clinics existed in Tehran alone and 8,000 across the country. They offer primary health check-ups, HIV tests, antiretroviral therapy, and help with hepatitis and tuberculosis treatment.
The director of one such Tehran clinic, Dr. Mohammad Fallah, told the Financial Tribune that patients are given methadone and buprenorphine, as well as laudanum (an opium tincture) as part of substitution therapy programs. All of these drugs are produced by pharmaceutical companies, and medical professionals closely monitor their use.
«These substances are much safer than those supplied through the smuggling chain, because the dosage and quality of artisanal opium is often questionable, and the prices are much higher. About six months ago, a significant number of patients were hospitalized due to smoking lead-poisoned opium. Smugglers often mix lead or even X-ray films with opium to increase the weight of their product» — Fallah said.
Fallah said substitution treatment programs attract many respectable patients, from government employees to doctors to police officers, and allow them to keep their families and jobs.
«These people take the medications their bodies need on a daily basis and live normal lives without posing a threat to society»
— Fallah concludes.
— Fallah concludes.
