ORIGINAL ARTICLE

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HIGH-RISK BEHAVIOURS AND CONCOMITANT MEDICAL ILLNESSES AMONG PATIENTS AT METHADONE MAINTENANCE THERAPY CLINIC, HOSPITAL TENGKU AMPUAN AFZAN, MALAYSIA

Ramli M¹ MD, MMed(Psychiatry), Nora MZ¹ MD, MMed(Psychiatry), Zafri AAB² MBBS,MMed(Psychiatry), Junid MR² MMed, MMed(Psychiatry), Umeed AK1 MBBS, MCPS, Hajee MI1 MBBS, DPM
1. Kulliyyah of Medicine, International Islamic University Malaysia, Bandar Indera Mahkota, 25200 Kuantan, Pahang, Malaysia [Ramli Musa, Nora Mat Zin, Umeed Ali Khan, Hajee Mohamad Ismail]
2. Department of Psychiatry, Hospital Tengku Ampuan Afzan, 25150, Kuantan, Pahang, Malaysia [Ahmad Zafri Abu Bakar, Junid Mohamed Rozali]

Address for correspondence: Dr Ramli Musa, Department of Psychiatry, Kulliyyah of Medicine, International Islamic University Malaysia, Bandar Indera Mahkota, 25200 Kuantan, Pahang, Malaysia. Tel: +609 5716400 / +6012 2484076, Fax: +609 5716770,
Email: ramlidr@yahoo.com

Conflict of interest: None

BACKGROUND

Chronic opiate dependence is a real menace to the Malaysian society and a threat to the mission of human capital development. The associated complications, such as HIV infections, hepatitis infections, escalating crime rates, psychosocial disabilities and drug-related psychiatric disorders, are serious medical and social problem.¹ Over two-thirds of HIV/AIDS cases in Malaysia were injecting drug users particularly heroin use.²

In Malaysia, the Methadone Maintenance Therapy (MMT) programme to treat opioid dependence was started in mid 2005. Now it has become a national programme and one of the government’s strategies to combat this problem. The Ministry of Health Malaysia has directed that methadone be a heavily regulated medicine to prevent potential negative implications.³

The Methadone Maintenance Therapy (MMT) at the psychiatric clinic in the Department of Psychiatry, Hospital Tengku Ampuan Afzan was established in early 2007. Two years into the programme, we conducted an evaluation of its strengths and weaknesses in order to improve our service delivery. The outcomes of this study may also reflect positive effects of MMT programme in Malaysia in fighting the social-related problems of opioid dependence. However, the evaluation can only be done retrospectively as the same authors are also embarked on another on-going prospective study to evaluate the effectiveness of the MMT programme.

METHODS

This was a retrospective review of case records over 2 years (January 2007 to December 2008). The study was approved by the internal review board of International Islamic University and the Ethics Committee of Hospital Tengku Ampuan Afzan, Pahang.

The Opiate Treatment Index (OTI), a structured interview designed to provide a measure of the effectiveness of drug treatments, was assessed in all patients in the MMT programme. The OTI measures 6 treatment outcomes: drug use, HIV risk-taking behaviour, social functioning, criminality, health status and psychological functioning.⁴ OTI has been used as the main tool of assessment in the MMT programme in Malaysia. In this study, we only used the first 4 selected components of the instrument. Administration of OTI was only done once during the enrolment of the subjects in the MMT programme.

The specific objectives of the study were to determine: (1) the pluralities of substance abuse; (2) the pattern of high-risk behaviours of patients attending Methadone Maintenance Treatment; and (3) the compliance rate and (4) the common doses of methadone used.

RESULTS

Table 1 shows three-quarters of the registered patients were aged between 21 and 40 years (ages ranged from 22-57 years, median 35 years). Only 3 out of 172 patients were females. About 97% of them were Malays and 98% were Muslims. Two-thirds of them were single. The majority of the patients (70.1%) were employed at the time of treatment initiation; most of them were blue collar workers. Of those who were employed, 62% indicated difficulty in securing a job.

Table 2 shows the pattern of substance misuse. Almost all of them used heroin. However, significant proportions were using other psychoactive substances: morphine 26%, benzodiazepines 23%, cannabis 42% and ketum leaf 19%. Two-thirds of the patient started psychoactive substance abuse at a very early life (13 to 20 years old) and the mean duration of abuse was 14 years. Half of them started to abuse drugs due to curiosity on the substance. About one in ten patients had family history of substance abuse. One-third of them had been admitted at least 3 times to rehabilitation centres.

As shown in Table 3, almost all patients were hepatitis C positive while a quarter of them were HIV positive. Most of them (90%) were intravenous drug users (IVDU), with 23% of them reported sharing needles at least once in the last one month of the enrolment. However, 46% of the patients cleaned the needles before re-using them. Four-fifths of the patients were not sexually active and 2.8% had multiple sexual partners. Among those who were sexually active, 77% never used a condom, 6% practiced anal sex during the last 1 month prior to their enrolment.

Almost all of respondents were engaged in property crimes (92%) and a few were involved in other criminal activities in a month prior to their enrolment to the programme. Nevertheless the crime-related figures may not reflect the actual situation due to substantial missing data (17%). The low percentage of involvement in crime may also be questioned because a total of 109 out of 145 patients (75%) had been in prison before. The most likely reasons for imprisonment were drug-related crimes; 30% of them had been in prison three or more times.

The initial starting dose of methadone was 25-30 mg in 76% of respondents; the maintenance dose was 35-50 mg in 65% of respondents. Two years after the commencement of MMT clinic, we found the retaining rate to the programme was 63%.

Table 1: Demographic characteristics of patients in the MMT programme

Characteristics	Number* (%)
Age (years)
21-30	44 (25.6)
31-40	82 (47.7)
41-50	37 (21.5)
51-60	9 (5.2)
Race
Malay	167 (97.1)
Chinese	5 (2.9)
Religion
Muslim	168 (97.7)
Buddhist	3 (1.7)
Others	1 (0.6)
Marital status
Single	111 (67.3)
Married	48 (29.1)
Divorced/widowed	6 (3.6)
Educational Level
No formal education/primary school	18 (10.7)
Form 3 secondary school	50 (29.8)
Form 5 secondary school	95 (56.6)
College/graduate	5 (3.0)
Employment Status
Employed	110 (70.1)
Unemployed	47 (29.9)
Types of occupation
Professional/technical/managerial	1 (1.0)
Agricultural/fishery/forestry	4 (3.8)
Military/police/fireman	1 (1.0)
Factory worker	12 (11.5)
Clerical/sales	7 (6.7)
Service	12 (11.5)
Own a business	29 (27.9)
Others	38 (36.5)
Reasons for unemployment
Unable to work	5 (19.2)
Unable to get a job	16 (61.5)
Not applicable	3 (11.5)
Housewife	1 (3.8)
Student	1 (3.8)

*Total is variable for each subgroup due to missing data