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Compulsory drug detention center experiences among a community-based sample of injection drug users in… Csete, Joanne; Kaplan, Karyn; Hayashi, Kanna; Fairbairn, Nadia; Suwannawong, Paisan; Zhang, Ruth; Wood, Evan; Kerr, Thomas Oct 20, 2011

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RESEARCH ARTICLE Open AccessCompulsory drug detention center experiencesamong a community-based sample of injectiondrug users in Bangkok, ThailandJoanne Csete1, Karyn Kaplan2, Kanna Hayashi3,4, Nadia Fairbairn3, Paisan Suwannawong2, Ruth Zhang5,Evan Wood3,4 and Thomas Kerr3,4*AbstractBackground: Despite Thailand’s official reclassification of drug users as “patients” deserving care and not“criminals,” the Thai government has continued to rely heavily on punitive responses to drug use such as “bootcamp"-style compulsory “treatment” centers. There is very little research on experiences with compulsory treatmentcenters among people who use drugs. The work reported here is a first step toward filling that gap.Methods: We examined experiences of compulsory drug treatment among 252 Thai people who inject drugs(IDU) participating in the Mitsampan Community Research Project in Bangkok. Multivariate logistic regression wasused to identify factors independently associated with a history of compulsory treatment experience.Results: In total, 80 (31.7%) participants reported a history of compulsory treatment. In multivariate analyses,compulsory drug detention experience was positively associated with current spending on drugs per day (adjustedodds ratio [AOR] = 1.86; 95%CI: 1.07 - 3.22) and reporting drug planting by police (AOR = 1.81; 95%CI: 1.04 - 3.15).Among those with compulsory treatment experience, 77 (96.3%) reported injecting in the past week, and nodifference in intensity of drug use was observed between those with and without a history of compulsory detention.Conclusion: These findings raise concerns about the current approach to compulsory drug detention in Thailand.Exposure to compulsory drug detention was associated with police abuse and high rates of relapse into drug use,although additional research is needed to determine the precise impact of exposure to this form of detention onfuture drug use. More broadly, compulsory “treatment” based on a penal approach is not consistent with scientificevidence on addressing drug addiction and should be phased out in favor of evidence-based interventions.Keywords: Compulsory treatment, Thailand, injection drug useBackgroundThe United Nations estimates that about one-third ofnew HIV transmissions outside of sub-Saharan Africa arelinked to injection drug use [1]. In some regions, includ-ing much of eastern Europe and parts of east and south-east Asia, contaminated injecting equipment is thesource of the majority of new infections [2]. Ensuringaccess to sterile injecting equipment and to humane andscientifically sound treatment for drug dependence,including methadone maintenance therapy, should becentral elements of HIV prevention in countries whereinjection drug use is linked to HIV transmission. Unfor-tunately, in many countries needle and syringe programs(NSP), including needle exchange, are politically unpopu-lar and inaccessible for the majority of those who need it[3,4]. Relatively few countries make it a priority to ensureaffordable and evidence-based treatment of drug depen-dence to all who need it [5].Where illicit drug use is heavily criminalized, healthservices for people who inject drugs may be influenced orcontrolled by criminal law authorities. Treatment fordrug dependence may be compulsory under the law.Various forms of compulsory or mandated drug depen-dence treatment, including drug courts, have been* Correspondence: uhri-tk@cfenet.ubc.ca3Department of Medicine, University of British Columbia, 2775 Laurel Street,10th Floor, Vancouver, British Columbia V5Z 1M9, CanadaFull list of author information is available at the end of the articleCsete et al. BMC International Health and Human Rights 2011, 11:12http://www.biomedcentral.com/1472-698X/11/12© 2011 Csete et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.implemented in various settings. While evaluations havesuggested some benefits of this type of approach, includ-ing reductions in drug-use-related criminal activity [6], anumber of commentators have raised methodologicalconcerns about existing evaluations (e.g., lack of data onpost-release drug use, failure to incorporate intent-to-treat analyses, use of inappropriate control comparisongroups) [7-11]. Further, recent reviews have suggestedthat the literature pertaining to compulsory or mandatedtreatment is highly inconsistent, and that this type ofapproach is less effective than voluntary treatment [8,12].Concerns have also been raised about ethical issuesrelated to compulsory treatment and the potential forassociated human rights violations [10]. Still, there issome evidence indicating the benefits of offering integrat-ing drug dependence treatment within criminal justicesystems [6,13].In a number of countries, including in southeast Asia,compulsory drug treatment includes prison-like detentionand such practices as forced labor [14]. A recent WHOreport examined compulsory drug detention centers inCambodia, China, Malaysia, and Vietnam. Most centersare operated by staff from the military or public securitysector, although some centers (primarily those in Malaysiaand China) include a small number of healthcare profes-sionals (nurses, counselors, physicians). Most centers failto employ evidence-based approaches for treating drugdependence and instead rely on forced detoxification(medically-assisted in some cases), labor, educationalapproaches, and physical exercise [14]. In a 2009 report tothe UN Human Rights Council, the former UN SpecialRapporteur on Torture underscored that non-consensualtreatment for drug dependence violates both scientific andhuman rights norms [15]. Empirical data on the healthimpact of compulsory drug detention centers in the regionare scant. Accounts from a number of Asian countriessuggest that persons undergoing this punitive “treatment”suffer physical and psychological harms, as well as highrates of relapse to drug use [16,17].Thailand has been widely praised for its response toHIV, which has resulted in demonstrable control of theepidemic in some population groups, including sex work-ers[18]. Sexual transmission of HIV declined by more than80% in Thailand between 1991 and 2001[19]. Among peo-ple who use illicit drugs, however, HIV prevalence hasremained at about 40-50% over a long period [20,21].Thailand has been criticized for failing to ensure access toNSP, methadone therapy, and other humane treatment fordrug dependence [22]. In spite of a 2002 law that reclassi-fied people who use illicit drugs as “patients” to be caredfor, rather than criminals to be punished [23], the Thaigovernment continues to rely heavily on compulsory drugdetention–bangkap bambat or “forced treatment” inThai–that almost always includes significant periods ofprison-like detention [24,25]. Although the compulsorydrug detention system was conceived as an alternative toincarceration, people mandated for this treatment are fre-quently detained in prison for about 45 days while theircases are being assessed [24,25]. A recent review revealedthat the majority of the 84 centers in operation in 2008were run by the Royal Thai Army, Air Force, or Navy [24].Centers run by the military typically house between 100and 400 individuals, while a smaller number of centersrun by the Ministry of the Interior tend to house between30 and 50 individuals. Individuals usually stay betweenthree and six months in compulsory drug detention cen-ters, although this period can be extended upon review.Activities within the centers typically involve intensivephysical exercise akin to that found in military “bootcamps,” group work common among therapeutic commu-nities, and vocational training. There have also beenreports of cruel, inhuman, and degrading punishmentwithin such centers [24]. From October 2008 to June2009, there were an estimated 39,287 people in compul-sory drug detention centers in Thailand [26].There is little published information on the experienceof compulsory drug detention in Thailand from the pointof view of people living with drug dependence. Therefore,we sought to identify the prevalence and correlates ofcompulsory drug treatment exposure among a commu-nity-recruited sample of Thai people who inject drugs(IDU).MethodsParticipant RecruitmentThe Mitsampan Community Research Project (MSCRP)is a collaborative research project involving the BritishColumbia Centre for Excellence in HIV/AIDS (Vancou-ver, Canada), the Mitsampan Harm Reduction Center(Bangkok, Thailand), the Thai AIDS Treatment ActionGroup (Bangkok, Thailand), and Chulalongkorn Univer-sity (Bangkok, Thailand). In July-August 2008, theresearch partners undertook a cross-sectional studyinvolving 252 community-recruited IDU. Participantswere recruited through peer-based outreach efforts andword of mouth and were invited to attend the MitsampanHarm Reduction Center to be part of the study. To beeligible to participate in this study, individuals had tohave injected at least once in the previous six months. Allparticipants provided informed consent and completedan interviewer-administered questionnaire elicitingdemographic data as well as information about drug use,HIV risk behavior, interactions with police and the crim-inal justice system, and experiences with health care,including compulsory “treatment.” Participants received astipend of 250 Thai Baht (approximately US$7) uponCsete et al. BMC International Health and Human Rights 2011, 11:12http://www.biomedcentral.com/1472-698X/11/12Page 2 of 6completion of the questionnaire. The study was approvedby the Research Ethics Boards of the University of BritishColumbia and Chulalongkorn University.Statistical AnalysesThe primary outcome of interest in this analysis was ahistory of compulsory drug detention experience amongIDU. We compared IDU who did and did not report ahistory of compulsory drug detention experience usingunivariate statistics and multivariate logistic regression.Variables considered included: median age (< 36.5 yearsvs. ≥ 36.5 years), gender, education level (up to secondaryschool vs. secondary school or higher), current employ-ment (unemployed vs. employed), current illegal incomegeneration (yes vs. no), average amount of money spenton drugs per day (> 300 vs. ≤ 300 Thai Baht or US$9),heroin injection ever (yes vs. no), methamphetamineinjection ever (yes vs. no), methadone injection (i.e., illicitmethadone use) ever (yes vs. no), overdosed ever (yes vs.no), use of drugs in combination (yes vs. no), syringe bor-rowing ever (yes vs. no), syringe lending ever (yes vs. no),methadone treatment use ever (yes vs. no), and reportinga history (yes vs. no) of drug planting by police (i.e.,police have ever planted illicit drugs on one’s person). Toexamine the bivariate associations between each indepen-dent variable and compulsory treatment experience, weused the Pearson c2 test. Fisher’s exact test was usedwhen one or more of the cells contained values less thanor equal to five. We then applied an a priori defined sta-tistical protocol by fitting a multivariate logistic regres-sion model that included all variables that weresignificantly associated with compulsory drug detentionexperience at the p ≤ 0.05 level in univariate analyses. Allp-values were two-sided. We also investigated the preva-lence of injection drug use in the past week among thosewho reported a history of compulsory drug detention. Aswell, we compared intensity of recent injection drug use(≥ daily injecting vs. < daily injecting) among those whodid and did not report a history of compulsory drugdetention experience using the Pearson c2 test.ResultsIn total, 252 IDU participated in this study; 66 (26.2%)were female, and the median age was 36.5 years. A totalof 80 (31.7%) participants reported a history of compul-sory detention. Table 1 presents the univariate analysesof factors associated with compulsory drug detentionexperience. Compulsory drug detention experience waspositively associated with spending > 300 Thai Baht perday on drugs (odds ratio [OR] = 1.90; 95% confidenceinterval [CI]: 1.11 - 3.27), use of drugs in combination(OR = 1.99; 95%CI: 1.07 - 3.69), and ever having experi-enced drug planting by police (AOR = 1.99; 95%CI: 1.16- 3.41).Table 2 presents the multivariate analyses of factorsindependently associated with reporting a history of com-pulsory drug detention experience. As shown here, com-pulsory drug detention experience was positivelyassociated with spending > 300 baht per day on drugs(adjusted odds ratio [AOR] = 1.86; 95%CI: 1.07 - 3.22)and reporting drug planting by police (AOR = 1.81; 95%CI: 1.04 - 3.15). In subanalyses, among those with com-pulsory drug detention experience, 77 (96.3%) individualsreported injecting in the past week. Intensity of recentinjection drug use did not differ between those who wereand were not exposed to compulsory drug detention(p > 0.14).DiscussionAmong a community-recruited sample of Thai IDU,almost one-third had experienced compulsory drug deten-tion at some point. Having undergone compulsory drugdetention was associated with having had drugs plantedon one’s person by the police, reporting greater spendingon illicit drugs, as well as combination drug use (i.e., usingmore than one drug at a time). Virtually all (96.3%) ofthose who had undergone compulsory drug detentionreported having injected drugs in the week prior to beinginterviewed for this study, and intensity of recent injectingbehavior did not differ among those who were and werenot exposed to compulsory drug detention.Our finding of an association between compulsory drugdetention experience and drug planting by police buildson a substantial body of literature demonstrating harmsfrom and police corruption associated with drug enforce-ment policing [27,28], and raises concerns about the tac-tics used to force drug users into compulsory drugdetention settings. This association may indicate thatsome individuals had drugs planted on them as policeworked to meet quotas for arrest that were established aspart of Thailand’s state-sponsored “war on drugs” [29].Alternatively, this association may reflect a breach of con-fidentiality in that police can identify and target individualswho have previously been in treatment. In any case, thesefindings indicate a need to investigate policing practiceswith an eye toward reform.One possible explanation for our finding of high ratesof active drug use among those IDU exposed to compul-sory drug detention is that these individuals were morelikely to be high-intensity drug users prior to beingdetained. Another potential explanation is that our sam-ple was biased toward active drug users. To be eligible toparticipate in our study, individuals had to have injectedonly once in the past six months. Therefore, participantscould have been exposed to compulsory drug detentionand ceased injecting in the past six months and still beeneligible to participate in the study. Still, our sample maybe over-representative of those who relapsed after beingCsete et al. BMC International Health and Human Rights 2011, 11:12http://www.biomedcentral.com/1472-698X/11/12Page 3 of 6in compulsory drug detention and may under-representthe population of IDU who ceased injecting followingexposure to this type of program. However, is also possi-ble that such centers may be failing to meet the statedgoal of promoting reductions in or abstinence from druguse. It is notable that our results concerning post-com-pulsory drug detention drug use are strikingly similar tofindings from evaluations of compulsory drug detentionTable 1 Factors associated with compulsory drug detention exposure among IDU in Bangkok, Thailand (n = 252)Characteristic Yesn = 80 (31.7%)Non = 172 (68.3%)Odds Ratio(95% CI)p - valueMedian age< 36.5 years 45 (56) 81 (47) 1.44 (0.85 - 2.46) 0.176≥ 36.5 years 35 (44) 91 (53)GenderFemale 23 (29) 43 (25) 1.21 (0.67 - 2.19) 0.529Male 57 (71) 129 (75)Education≥ secondary 57 (71) 102 (59) 1.70 (0.96 - 3.01) 0.067< secondary 23 (29) 70 (41)UnemployedYes 16 (20) 30 (17) 1.18 (0.60 - 2.32) 0.625No 64 (80) 142 (83)Income from illegal sourcesYes 7 (9) 7 (4) 2.26 (0.77 - 6.68) 0.146No 73 (91) 165 (96)Median daily expenses for purchasing drugs≥ 300 THB 49 (61) 78 (45) 1.90 (1.11 - 3.27) 0.019< 300 THB 31 (39) 94 (55)Ever injected heroinYes 78 (97) 156 (91) 4.00 (0.90 - 17.84) 0.051No 2 (3) 16 (9)Ever injected yabaYes 54 (68) 107 (62) 1.26 (0.72 - 2.21) 0.416No 26 (32) 65 (38)Ever injected methadoneYes 13 (16) 26 (15) 1.09 (0.53 - 2.25) 0.817No 67 (84) 146 (85)Ever used drugs in combinationYes 63 (79) 112 (65) 1.99 (1.07 - 3.69) 0.029No 17 (21) 60 (35)Ever borrowed needlesYes 32 (40) 57 (33) 1.35 (0.78 - 2.33) 0.289No 48 (60) 115 (67)Ever lent needlesYes 29 (36) 63 (37) 0.98 (0.57 - 1.71) 0.954No 51 (64) 109 (63)Ever overdosedYes 30 (38) 45 (26) 1.69 (0.96 - 2.98) 0.067No 50 (62) 127 (74)Ever had drugs planted by policeYes 48 (60) 74 (43) 1.99 (1.16 - 3.41) 0.012No 32 (40) 98 (57)Ever on methadone treatmentYes 40 (50) 71 (41) 1.42 (0.83 - 2.42) 0.194No 40 (50) 101 (59)Csete et al. BMC International Health and Human Rights 2011, 11:12http://www.biomedcentral.com/1472-698X/11/12Page 4 of 6in China, which is estimated to have relapse rates ofabout 95% [16]. A World Health Organization (WHO)report suggests that the ineffectiveness of compulsorydrug detention in Cambodia, China, Malaysia, andVietnam is due not only to the lack of evidence-basedpractices in treating drug dependence but also to the lackof access to condoms and antiretroviral therapy in com-pulsory facilities [14]. Whatever its effectiveness, it isclear that compulsory drug detention in Thailand violatesinternational norms. Noting that drug treatment “shouldnot be forced on patients,” WHO enjoins governments tolimit compulsory treatment to “exceptional crisis situa-tions of high risk to self or others” and specified periodsof time [30]. In 2010, the executive director of the GlobalFund to Fight AIDS, Tuberculosis and Malaria, MichelKazatchkine, called for closure of compulsory detentionof IDU under the guise of treatment and an end to the“repugnant abuses” in drug detention facilities [31]. TheUN Special Rapporteur on Torture urged national gov-ernments to “ensure that their legal frameworks govern-ing drug dependence treatment and rehabilitationservices are in full compliance with international humanrights norms” [15].Exposure to compulsory drug detention was also asso-ciated with greater current expenditure for drugs. Thiscould be explained by a selection effect, whereby compul-sory drug detention selects for IDU who spend more ondrugs, or alternatively, that being exposed to compulsorydrug detention is associated with psychological sequelaeresulting in greater spending on drugs and possibly higherintensity drug use (in this case, injecting or non-injecting).As HIV among IDU remains a major public health pro-blem in Thailand, the Thai government should be urgedto concentrate on increasing access to proven means ofHIV prevention in this population, including needleexchange and evidence-based treatment for drug depen-dence. Independent scrutiny of compulsory drug detentioncenters–that is, by investigators not linked to those run-ning the treatment centers–is urgently needed, includingof activities that may undermine the health or humanrights of patients. It is an accepted principle, moreover,that no one treatment option works for all drug users [30].The Thai authorities should focus on improving access toa range of humane and effective voluntary treatmentoptions. Access to good quality methadone therapy, forexample, remains very limited in Thailand [32,33].This study is limited in several ways. The study sampleof persons using the Mitsampan Harm Reduction Centerwas not randomly selected. It may therefore not be possi-ble to generalize the findings of this study to Thai drugusers more broadly. However, a strength of this study is itsuse of a community-recruited sample, rather than a sam-ple selected from a treatment facility. The data are alsobased on self-report by drug users and may therefore besusceptible to response bias, including socially desirableresponding. However, the participants in this study wereblinded to the eventual use of this data; it is therefore unli-kely that responses related to sensitive items (e.g., recentdrug use) would be differentially reported by those withand without a history of compulsory drug detention. Inaddition, as noted above, the data do not permit detailedanalysis of the compulsory drug detention experience thatwould enable recommendations for improving therapeuticelements or analysis of the timing of relapse post-treat-ment. Lastly, as mentioned above, we purposively selecteda sample of IDU who had injected at least once in the pre-vious six months, and therefore our findings pertaining tothe potential effects of compulsory drug detention onrecent drug use may be limited by selection effects. How-ever, we note that our findings concerning rates of relapseare strikingly similar to findings observed in other settings[16].ConclusionThe stated policy of the Thai government that people liv-ing with drug dependence should be regarded as patientsrather than criminals is in principle an important steptoward an environment conducive to ensuring access tohumane and effective health services for IDU. The find-ings of this study indicate that the principle is a long wayfrom reality. The Thai government should phase outcompulsory drug detention according to internationalrecommendations, and in the immediate period shouldopen all treatment facilities to independent scrutinywhile working to remove barriers to voluntary, evidence-based health services for this neglected population.Table 2 Multivariate logistic regression analysis of factors associated with compulsory drug detention exposureamong Thai IDU (n = 252)Variable Adjusted Odds Ratio (AOR) 95% Confidence Interval (CI) p - valueEver used drugs in combination(yes vs. no) 1.78 (0.94 - 3.36) 0.078Ever had drugs planted by police(yes vs. no) 1.81 (1.04 - 3.15) 0.035Median daily expenses for purchasing drugs(≥ 300 THB vs. < 300 THB) 1.86 (1.07 - 3.22) 0.028Csete et al. BMC International Health and Human Rights 2011, 11:12http://www.biomedcentral.com/1472-698X/11/12Page 5 of 6AcknowledgementsWe would particularly like to thank the staff and volunteers at theMitsampan Harm Reduction Center for their support. We also thank Dr.Niyada Kiatying-Angsulee of the Social Pharmacy Research Unit (SPR), Facultyof Pharmaceutical Sciences, Chulalongkorn University for her assistance withdeveloping this project. We also thank Daniel Miles Kane, Deborah Grahamand Calvin Lai for their assistance with data management, and PrempreedaPramoj Na Ayutthaya and Donlachai Hawangchu for their assistance withdata collection.Author details1Heilbrunn Department of Population and Family Health, Mailman School ofPublic Health, Columbia University, 50 Haven Avenue, New York, NY 10032USA. 2Thai AIDS Treatment Action Group, 18/89 Vipawadee Road, soi 40Chatuchak, Bangkok 10900 Thailand. 3Department of Medicine, University ofBritish Columbia, 2775 Laurel Street, 10th Floor, Vancouver, British ColumbiaV5Z 1M9, Canada. 4British Columbia Centre for Excellence in HIV/AIDS, 608 -1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada. 5ProvincialHealth Services Authority, 700 - 1380 Burrard Street, Vancouver, BritishColumbia V6Z 2H3, Canada.Authors’ contributionsTK, KK, KH, PS, NF designed the overall study, RZ, TK, and EW designed andundertook the analyses specific to this manuscript, JC and KK prepared thefirst draft of the manuscript and all authors provided input on each draft ofthe manuscript. All authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 24 January 2011 Accepted: 20 October 2011Published: 20 October 2011References1. UNAIDS (Joint United Nations Programme on HIV/AIDS): Joint UNAIDSstatement on HIV prevention and care strategies for drug users. Geneva;2005 [http://data.unaids.org/UNA-docs/cco_idupolicy_en.pdf].2. UNAIDS (Joint United Nations Programme on HIV/AIDS): AIDS epidemicupdate 2009. Geneva; 2009 [http://data.unaids.org/pub/Report/2009/JC1700_Epi_Update_2009_en.pdf].3. Kerr T, Wood E: Misrepresentation of science undermines HIV prevention.Can Med Assn J 2008, 178:964.4. Global HIV Prevention Working Group: Bringing HIV prevention to scale:An urgent global priority. 2007 [http://www.globalhivprevention.org/pdfs/PWG-Scaling-Up-ExecSumm.pdf].5. 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J Urban Health 2003, , 80: iii97-105.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-698X/11/12/prepubdoi:10.1186/1472-698X-11-12Cite this article as: Csete et al.: Compulsory drug detention centerexperiences among a community-based sample of injection drug usersin Bangkok, Thailand. BMC International Health and Human Rights 201111:12.Csete et al. BMC International Health and Human Rights 2011, 11:12http://www.biomedcentral.com/1472-698X/11/12Page 6 of 6

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