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

Table 2: Pattern of substance abuse

Characteristics	Number* (%)
Types of drug abuse**
Heroin	157 (96.9)
Morphine	43 (26.5)
Cannabis	68 (42.0)
Methamphetamine	42 (25.9)
Benzodiazepines	37 (22.8)
Codeine	31 (19.1)
Glue sniffing	4 (2.5)
Lysergic acid diethylamide (LSD)	9 (5.6)
Ketum leaf	30 (18.5)
Starting age of drug abuse
13-20	108 (66.7)
21-30	50 (30.9)
31-40	4 (2.4)
Reasons for drug abuse
Peer influence	58 (37.2)
Curiosity	77 (49.4)
Stress	17 (10.9)
Family problem	4 (2.5)
Family history of drug abuse
Yes	19 (13.8)
No	119 (86.2)
Source of referral
National Anti-Drug Agency***	4 (2.6)
Walk-in	89 (56.7)
Friend	33 (21.0)
Non-governmental Organisation	31 (19.7)
Admission to rehabilitation centres
Never	65 (45.1)
1-2	38 (26.4)
3-6	41 (28.5)

*Total is variable for each subgroup due to missing data
**Some patients abused more than one drug
*** National Anti-Drug Agency is known as Agensi Anti-Dadah Kebangsaan (AADK) in Malay

Table 3. Health status and patterns of high-risk behaviours among drug users

Characteristics	Number* (%)
Health Status
Healthy	10 (6.9)
Sick	134 (93.1)
Hepatitis B positive	4 (2.3)
Hepatitis C positive	165 (95.9)
HIV positive	40 (23.3)
Pattern of injection intravenous drug users
1. In the last month how many times did you inject drugs
Never	9 (6.3)
Once or more than once a week	19 (13.2)
Everyday	116 (80.5)
2. How many times in the last month did you use someone else’s needle?
Never	111 (77.1)
1-2 times	15 (10.4)
3 or more times	18 (12.5)
3. How often in the last month have you cleaned your needles before re-using them?
Never re-use	35 (24.3)
Every time	66 (45.8)
Often or rarely	38 (26.4)
Never	5 (3.5)
Sexual behaviours
1. How many people have you had sex with in the last month?
None	117 (81.8)
1	22 (15.4)
2 or more people	4 (2.8)
2. How often have you used condoms in the last month?
No regular partner/no penetrative sex	93 (65.5)
Every time	6 (4.2)
Often	1 (0.7)
Sometimes	4 (2.8)
Never	38 (26.8)
3. How many times did you have anal sex in the last month?
Never	135 (94.4)
Once or 2 times	6 (4.2)
3 times or more	2 (1.4)
Criminal activities
1. How many times in the last month have you committed a property crime?
Never	131 (91.6)
Less than once a week	12 (8.4)
2. How many times in the last month have you sold drugs to someone?
Never	136 (95.1)
Once or less a week	4 (2.8)
Daily	3 (2.1)
3. How many times in the last month have you committed a fraud?
Never	142 (99.3)
Less than once a week	1 (0.7)
4. How many times in the last month have you engaged in a violent crime?
Never	141 (98.6)
Once a week	2 (1.4)
5. How many times have you been to prison?
Never	36 (24.8)
1 - 3 times	81 (55.9)
4 - 11 times	28 (19.4)

*Total is variable for each subgroup due to missing data

DISCUSSION

Patients enrolled in the Methadone Maintenance Programme (MMT) at the Department of Psychiatry, Hospital Tengku Ampuan Afzan, had similar characteristics to patients in other MMT centres in Malaysia such as in the University Malaya Medical Centre (UMMC).⁵ We found that both UMMC and our sites had patients who were mostly Malays, males and educated only up to secondary school level. In both centres most of the patients were employed and they were either self-employed or running a business.^5,6 Seventy-three percent of the patients in HTAA were aged between 21 and 40 years old, while 82% of the patients at UMMC were below the age of 49 years. Majority (67%) of the subjects at HTAA were, however, single (as compared to less than half (48%) in UMMC.⁵

Previous studies have proven that patients on MMT retained their jobs and have improved overall performance.⁷ Therefore, as most of the patients (64%) were employed, ensuring quality service and improving the MMT programme of this programme may help them to retain their jobs. On the other hand, 62% of those who were unemployed stated that they had difficulty in securing a job. One of the possible reasons that we could postulate to contribution to high unemployment rate is due to the society’s stigma against this group.

There are a few lessons we could learn by looking at the patterns of substance misuse. Drugs such as methamphetamine, benzodiazepines and ketum leaf were popular among this population as about a quarter of them were abusing these types of substance. Ketum leaf, an indigenous psychoactive plant (scientific name Mitragyna speciosa) is popular in the east coast region of Peninsular Malaysia and South Thailand. It contains mitragynine which is an alkaloid psychoactive ingredient and produces stimulant, sedative and euphoric effects. These effects are similar to the effects of cannabis.⁸

The majority of patients started substance abuse in their teenage or young adult years. A total of 108 subjects (63%) started substance abuse before the age of 20 years and 39 subjects (23%) started during their early twenties. This indicated that teenagers and young adults are vulnerable groups and we need to focus our primary preventive efforts at a very early age. This can be done by concerting our efforts to educate the school children about the danger of drug abuse.

In terms of health, most of the patients were not well but we were unable to define or determine the causes of their illnesses. Nevertheless, almost all of them were hepatitis C positive while only 2% were hepatitis B positive. A substantial amount (23%) of the respondents was HIV positive.

High-risk behaviours such as sexual practice, needle sharing and criminal activities were also important factors. The majority (67%) of the subjects were single, and this may be the reason that 68% of them never had sex a month prior to the survey. Only 2.4% had multiple sex partners. A total of 4.7% practised anal sex within a month prior to their enrolment. There may have been more patients involved in deviant sexual practices and they may have refused to disclose this information (missing data in 17% of respondents).

The other high-risk behaviour was intravenous drug use. A total of 83% of the subjects had drug injected into their body in the last one month prior to their enrolment. Needle sharing was very common among this group and about 20% of the patients who shared a needle either used the needle after someone used it or another person used the needle after the patient used it. This figure is however low as compared to a study in Kelantan, 84% of drug users shared their injecting equipment.⁹ There was, however, an awareness about the importance of cleaning needles before reusing as 45% of the respondents cleaned their needles before reusing. Although a small percentage of them admitted to any criminal activities, previous records revealed that more than half of them had been imprisoned in the past. We conclude that this group practiced high-risk behaviours such as needle sharing, unprotected and deviant sexual activities and criminal activities. Based on all this facts, this clearly reflected the urgency to stress the importance of healthcare and medical intervention to contain their concurrent medical illnesses. Continuous education to address the risk of transmission among this group and their partners is a real need. A study in the past suggested that education on risk-taking behaviours through the media remains an essential approach.¹⁰

This study recorded that majority of the patients required dose of methadone between 30 to 50 mg per day. However in UMMC the dose required was lower. It was ranging from 10 mg a day to the maximum of 45 mg a day after 3 months in the programme at UMMC.¹¹ The highest reported dose of methadone was 580 mg per day, while in the UK most of the patients only needed doses of less than 50 mg per day to reduce withdrawal symptoms.¹²

In this study, we could not conclude that the MMT programme at HTAA is effective in combating the negative implications of opioid dependence. However other studies have shown that there is strong evidence of methadone’s effectiveness in reducing illicit drug use, crime rates, HIV transmission and mortality.^13,14 A prospective study is essential to evaluate this issue.

There are some limitations in this study as it was a retrospective review of the patients’ case notes. Hence it was subjected to recall bias or incomplete data. However in this study we found that most of the required data were available.

CONCLUSION

As these drug users practised high-risk behaviours such as needle sharing, using unclean needles and engaging in unprotected sexual activities, education and addressing these issues through media and public forum are important. We may also focus the education effort by using small group discussion targeting the IVDU community.  

ACKNOWLEDGEMENT

We wish to thank the Research Management Centre of International Islamic University Malaysia, for providing a research grant to conduct this study. We also extend our gratitude to our dedicated research assistants; Mr Aidil Faszrul Abdul Rahim, Mr Abdul Aziz Hamid, Mrs Norhayati Mohamed and Mr Nawawi Jantan. We also thank the original authors of OTI questionnaire for the usage of this scale in this study.              

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