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Drug use patterns among Thai illicit drug injectors amidst increased police presence Werb, Dan; Hayashi, Kanna; Fairbairn, Nadia; Kaplan, Karyn; Suwannawong, Paisan; Lai, Calvin; Kerr, Thomas Jul 21, 2009

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ralSubstance Abuse Treatment, ssBioMed CentPrevention, and PolicyOpen AcceShort ReportDrug use patterns among Thai illicit drug injectors amidst increased police presenceDan Werb1,2, Kanna Hayashi1, Nadia Fairbairn1, Karyn Kaplan3, Paisan Suwannawong3, Calvin Lai1 and Thomas Kerr*1,4Address: 1British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street Vancouver, Canada, 2School of Population and Public Health, University of British Columbia, Vancouver, Canada, 3Thai AIDS Treatment Action Group, 18/89 Vipawadee Road, soi 40 Chatuchak, Bangkok 10900, Thailand and 4Department of Medicine, University of British Columbia, Vancouver, CanadaEmail: Dan Werb - dwerb@cfenet.ubc.ca; Kanna Hayashi - kanna.hayashi@gmail.com; Nadia Fairbairn - n.fairbairn@gmail.com; Karyn Kaplan - karyn.kaplan@gmail.com; Paisan Suwannawong - paisan.suwannawong@gmail.com; Calvin Lai - clai@cfenet.ubc.ca; Thomas Kerr* - uhri-tk@cfenet.ubc.ca* Corresponding author    AbstractThailand has traditionally pursued an aggressive enforcement-based anti-illicit drug policy in aneffort to make the country "drug-free." In light of this ongoing approach, we sought to assessimpacts of enforcement on drug use behaviors among a cohort of injection drug users (IDU) inThailand. We examined drug use patterns among IDU participating in a cross-sectional studyconducted in Bangkok (n = 252). Participants were asked to provide data regarding patterns of druguse in the previous six months, including types of drugs consumed, method of consumption,frequency of use, and weekly income spent on drugs. We also conducted bivariate analyses toidentify a possible effect of a reported increase in police presence on measures of drug use andrelated risk behaviors among study participants. One hundred fifty-five (61.5%) individuals reportedinjection heroin use and 132 (52.4%) individuals reported injection midazolam use at least daily inthe past six months. Additionally, 86 (34.1%) individuals reported at least daily injection Yaba andIce (i.e., methamphetamine) use. Participants in our study reported high levels of illicit drug use,including the injection of both illicit and licit drugs. In bivariate analyses, no association betweenincreased police presence and drug use behaviors was observed. These findings demonstrate highongoing rates of drug injecting in Thailand despite reports of increased levels of strict enforcementand enforcement-related violence, and raise questions regarding the merits of this approach.FindingsDrug users in Thailand continue to face a variety of harms.In addition to the health risks associated with the con-sumption of illicit drugs through injection and othermeans, Thai drug users face stigmatization and an ele-vated risk of violence as a result of their government'scized "War on Drugs" aimed at disrupting a burgeoningdemand for methamphetamines [2]. The stated goal ofthis campaign was to make Thailand "drug free" by target-ing drug dealers [1,3]. It has been reported that over 2,200people, not necessarily drug dealers, were killed during itsimplementation [3]. Despite a massive outcry fromPublished: 21 July 2009Substance Abuse Treatment, Prevention, and Policy 2009, 4:16 doi:10.1186/1747-597X-4-16Received: 22 May 2009Accepted: 21 July 2009This article is available from: http://www.substanceabusepolicy.com/content/4/1/16© 2009 Werb et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5(page number not for citation purposes)'hard line' response to illicit drug use [1]. In February2003, the Thai government implemented a widely-publi-human rights groups and a government pledge to treatdrug users "as patients, not criminals" [4,5], the reinstitu-Substance Abuse Treatment, Prevention, and Policy 2009, 4:16 http://www.substanceabusepolicy.com/content/4/1/16tion of the Thai "War on Drugs" was announced in Febru-ary 2008. At that time, Thailand's interior ministerChalerm Yubamrong publicly stated that the crackdownwould continue even if "thousands of people have to die"[6].Little is known regarding the effect of the Thai War onDrugs on demand for illicit drugs, though recent studiessuggest that this campaign may have altered drug use pat-terns among illicit drug users and reduced consumptionof methamphetamine among youth in the short term[7,8]. However, the campaign may have also contributedto a systematic underreporting of illicit drug use andrelated risk behaviors and may have increased the misuseof diverted licit drugs [7]. This campaign was imple-mented in response to a massive increase in methamphet-amine use among Thais since the mid-1990s, as well as asteady increase in heroin injection that has been linked tothe effective eradication of the country's indigenousopium cultivation industry beginning in the 1970s [7].Research further suggests that the Thai government is con-tinuing to rely on drug crackdowns as a primary responseto illicit drug use in the country [9]. We therefore soughtto determine the effect of a perceived increase in policepresence on drug use patterns among a cohort of Thaiinjection drug users (IDU) after the announcement of asecond Thai "War on Drugs" in April 2008.The Mitsampan Community Research Project (MSCRP) isa collaborative research project involving the BritishColumbia Centre for Excellence in HIV/AIDS (Vancouver,Canada), the Mitsampan Harm Reduction Center (Bang-kok, Thailand), the Thai AIDS Treatment Action Group(Bangkok, Thailand), and Chulalongkorn University(Bangkok, Thailand). During July-August of 2008, theresearch partners designed and undertook a cross-sec-tional study involving IDU recruited from the communitythrough peer-based outreach efforts and word of mouth.Study participants were invited to attend the MitsampanHarm Reduction Center to participate in the study and allparticipants provided informed consent and completedan interviewer-administered questionnaire elicitingdemographic data as well as information about drug use,health risk behaviors, interactions with police and thecriminal justice system, and experiences with health care.All participants were given a stipend of 250 Baht uponcompletion of the questionnaire. The study has beenapproved by the Research Ethics Boards of the Universityof British Columbia and Chulalongkorn University.For the present analysis, participants were asked to pro-vide detailed data regarding patterns of drug use in theprevious six months, including types of drug consumed,cided with the implementation of a second "War onDrugs" by the Thai government. We also conducted bivar-iate analyses in which our dependent variable was a per-ceived increase in police presence. Specifically,participants were asked the following question: "In thepast six months, have you noticed an increase in policepresence where you obtain or use drugs?" Independentvariables of interest were defined as dichotomous meas-ures of frequent (i.e., ≥ daily vs. < daily) injection use ofheroin, Yaba or Ice use (i.e., two types of methampheta-mines; Yaba translates as "crazy drug" and is produced asa tablet that typically contains methamphetamine andcaffeine and is sometimes smoked, while Ice is a smokableform of methamphetamine), illicit (i.e., non-prescribed)methadone use, binge drug use (Yes vs. No), involvementin the sex trade (Yes vs. No) and involvement in drug treat-ment (Yes vs. No). We also conducted bivariate analysesbetween our dependent variable of interest (a perceivedincrease in police presence) and age and gender (male vs.female or transgender). All drug use and behavioral varia-bles refer to the six months prior to the interview. Weexamined the bivariate associations between each inde-pendent variable and a reported increase in police pres-ence using the Pearson X2 test. Fisher's exact test was usedwhen one or more of the cells contained values less thanor equal to five. Significance was set at the p ≤ 0.05 levelin our analyses. All p-values are two-sided.Two hundred and fifty-two individuals were recruited,including 66 (26.2%) women and 5 (2.0%) transgen-dered individuals. The median age was 36.5 years. Theaverage weekly income spent on drug use was 423 baht(approximately 12 USD). See additional file 1: Table S1for drug use frequencies reported by our cohort partici-pants. Heroin was the most commonly injected drug, with155 (61.5%) individuals reporting injection heroin use atleast once a day, and 229 (90.9%) individuals reporting atleast weekly injection use of heroin in the past six months.The second most commonly injected drug was mida-zolam, with 132 (52.4%) individuals reporting injectiondrug use at least once a day in the past six months. Also ofnote were high levels of Yaba and Ice use, with 86 (34.1%)participants reporting daily injection use and 58 (23.0%)participants reporting daily non-injection use of thesedrugs. Finally, 73 (29.0%) participants reported usingnon-injection illicit methadone at least once a day.In total, 137 (54.4%) participants reported observing anincrease in police presence where they purchase or con-sume drugs in the six months prior to being interviewed.When we performed bivariate analyses to determine thepossible association between a reported increase in policepresence and drug use patterns, we found no significantPage 2 of 5(page number not for citation purposes)method of consumption, frequency of use, and weeklyincome spent on purchasing drugs. This time period coin-associations between our dependent variable and meas-ures of drug use severity or the frequency of binge drugSubstance Abuse Treatment, Prevention, and Policy 2009, 4:16 http://www.substanceabusepolicy.com/content/4/1/16use, involvement in the sex trade, or uptake of addictiontreatment among our cohort. Results of bivariate analysesare shown in Table 1.In this cross-sectional study of drug use patterns among acohort of Thai IDU, we observed high reported levels ofdaily injection heroin, midazolam and methampheta-mine use, as well as high levels of daily non-injectionillicit methadone use. Additionally, although more thanhalf of the cohort participants reported observing anincrease in police presence in the six months prior tobeing interviewed, the time period following theannouncement of a renewed drug war, we found no sig-nificant bivariate associations between a perceivedincrease in police presence and a variety of indicators ofdrug use severity and related risk behaviors among ourcohort.The high levels of injection drug use and polydrug use thatwe observed among this cohort as well as the apparentnegligible impact of an increase in police presence onintensity of drug use or related risk behaviors raise con-cern given Thailand's continued reliance on an aggressive,and often violent, enforcement-based approach to drugcontrol [9]. The high level of injection midazolam use thatwe observed among study participants is also of interest.Midazolam is a prescription benzodiazepine and our datasuggest that some Thai IDU may be substituting illicitdrug use with the misuse of this licit drug. Previous studieshave found that a transition or increase in injection druguse as well as an initiation of, or increase in, misuse of licitdrugs may occur among drug using populations experi-encing an increase in drug enforcement or a decrease inthe supply of illicit drugs [8,10,11]. Studies of Thai IDUhave also suggested that increases in midazolam injectionmay have been related to declines in the availability ofheroin and subsequent increases in the price of this drug[12]. However, it is notable that heroin injection waswidespread among IDU in this cohort. It is also useful tocompare the drug use behaviours that we observed amongour cohort with results from other studies in our setting.For instance, in a study conducted by Wattana et al. usingdata from 2004, 19% of a cohort of IDU in Bangkokreported engaging in heroin injection and 2% reportedengaging in either injection midazolam or methampheta-mine use [13]. These levels are much lower than those weTable 1: Characteristics of Thai injection drug users stratified by reporting an increase in police presence in the last six months (n = 252)Reported an increase in police presenceCharacteristic Yes (n = 137) No (n = 115) Odds Ratio (95% CI)* P valueInjection heroin use<Daily 88 (64%) 67 (58%) 1.29 (0.77 – 2.14) 0.332≥Daily 49 (36%) 48 (42%)Yaba/Ice use<Daily 107 (78%) 81 (70%) 1.50 (0.85 – 2.65) 0.165≥Daily 30 (22%) 34 (30%)Midazolam use<Daily 97 (71%) 80 (70%) 1.06 (0.62 – 1.82) 0.831≥Daily 40 (29%) 35 (30%)Illicit methadone use<Daily 48 (35%) 36 (31%) 1.18 (0.70 – 2.01) 0.531≥Daily 89 (65%) 79 (69%)Binge drug use<Daily 59 (43%) 40 (35%) 1.42 (0.85 – 2.37) 0.181≥Daily 78 (57%) 75 (65%)Involvement in the sex tradeNo 17 (12%) 14 (12%) 1.02 (0.48 – 2.18) 0.955Yes 120 (88%) 101 (18%)Involvement in drug treatmentNo 67 (49%) 49 (43%) 1.29 (0.78 – 2.12) 0.318Yes 70 (51%) 66 (57%)Page 3 of 5(page number not for citation purposes)Note: Methadone use refers only to non-prescription (i.e., illicit) use*CI = Confidence IntervalSubstance Abuse Treatment, Prevention, and Policy 2009, 4:16 http://www.substanceabusepolicy.com/content/4/1/16observed in the present study, with 91% of participantsreporting injection heroin use, 66% reporting injectionmidazolam use, and 57% reporting injection metham-phetamine use. While these differences may reflect the dif-ferent sampling strategies used, the higher rates of druguse observed in the present study suggest that drug use hasnot declined since the first Thai War on Drugs was initi-ated in 2003. These results also raise questions concerninga possible effect of the Thai government's current responseto illicit drug use on the diversification of drug use pat-terns among this cohort. Further study is of this issue istherefore warranted. Specifically, future studies shouldattempt to track perceived police presence over time tofurther assess the impact of enforcement-based policiesand practices on drug use and related risks among ThaiIDU.Our study has several limitations. First, our sample wasnot randomly selected and our findings may not thereforebe generalizable to other Thai IDU. Second, due to thecross-sectional study design we caution against inferring acausal association between the independent variables weidentified in the present study and a reported increase inpolice presence among Thai IDU. Specifically, we wereunable to compare previous levels of midazolam useamong our cohort with the levels reported in this study.As such, we cannot conclude that midazolam use hasincreased among our sample, though it is noteworthy thatthe substitution of heroin for midazolam has beenobserved among other samples of Thai illicit drug users[12]. We were also unable to compare previous levels ofarrests with recent levels of arrests among our cohort par-ticipants, and we were therefore unable to determinewhether arrests increased among Thai IDU upon theimplementation of the second Thai War on Drugs, thoughreports from our study setting suggest that this likelyoccurred [2]. Further, although more longitudinalresearch is needed in this area, our study neverthelessreveals high levels of drug use and risk behavior in thepresence of an aggressive drug law enforcement campaign.Third, we relied on self-report and socially stigmatizedbehaviors may therefore have been underreported.Fourth, while we found no significant associationbetween a reported increase in police presence and anumber of indicators of drug use or risky drug usingbehaviors, this may be related to the size of the sampleincluded in this study. However, we note that we havebeen able to use this sample to detect associationsbetween drug use and HIV risk behaviors (syringe shar-ing) and drug-related harms (overdose) (data not shown),and we observed no trend towards a significant associa-tion between our independent and dependent variables.Regardless, we cannot rule out the possibility of a Type IIIn summary, we observed high levels of use of diversetypes of illicit and licit drugs by both injection and non-injection among a cohort of Thai IDU. We found no asso-ciation between a reported increase in police presence anda variety of indicators of intensity of drug use and relatedrisk behaviors. These findings, considered alongsidereports of extrajudicial killings and other human rightsviolations accompanying Thailand's drug control strategy,suggest that a reevaluation of the country's reliance onenforcement and violent crackdowns to curtail illicit druguse is urgently needed.Declaration of competing interestsThe authors declare that they have no competing interests.Authors' contributionsDW and TK drafted the original manuscript. KH coordi-nated data collection. NF, KH, KK and PS offered substan-tial revisions to the manuscript. All authors read andapproved the final manuscript.Additional materialAcknowledgementsWe would particularly like to thank the staff and volunteers at the Mitsam-pan Harm Reduction Center for their support. We also thank Dr. Niyada Kiatying-Angsulee of the Social Pharmacy Research Unit (SPR), Faculty of Pharmaceutical Sciences, Chulalongkorn University for her assistance with developing this project. We also thank Daniel Miles Kane, Deborah Gra-ham and Calvin Lai for their assistance with data management, and Prem-preeda Pramoj Na Ayutthaya and Donlachai Hawangchu for their assistance with data collection.Thomas Kerr and Dan Werb are supported by the Michael Smith Founda-tion for Health Research and the Canadian Institutes of Health Research. Further support is provided by CIHR Team Grant RAA-79918.References1. Ammesty International: Thailand: Grave developments – Kill-ings and other abuses.  Wanchai: Amnesty International; 2003:1. 2. Roberts M, Trace M, Klein A: Thailand's 'War on Drugs'.  In Drug-scope Briefing Papers Volume 5. London: Beckley Foundation; 2004:1-8. 3. HRW: Not enough graves.  New York: Human Rights Watch;2004. 4. Thepkanjana P: Keynote address at the observance of theUnited Nations International Day Against Drug Abuse andAdditional file 1Table S1. Prevalence and intensity of injection and non-injection drug use among a cohort of Thai injection drug users (n = 252). Description of drug use levels in the past 6 months among participants in the MSHRC cohort, Bangkok, Thailand.Click here for file[http://www.biomedcentral.com/content/supplementary/1747-597X-4-16-S1.pdf]Page 4 of 5(page number not for citation purposes)error. Illicit Trafficking.  2004 [http://www.un.org/depts/dhl/drug/index.html].Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Substance Abuse Treatment, Prevention, and Policy 2009, 4:16 http://www.substanceabusepolicy.com/content/4/1/165. Narcotic Addict Rehabilitation Act, B.E. 2545.  Government ofThailand; 2002. 6. Wong-Anan N: Thai PM vows "rigorous" war on drugs despiteoutcry.  Reuters. Bangkok 2008.7. Vongchak T, Kawichai S, Sherman S, Celentano DD, Sirisanthana T,Latkin C, Wiboonnatakul K, Srirak N, Jittiwutikarn J, Aramrattana A:The influence of Thailand's 2003 'war on drugs' policy on self-reported drug use among injection drug users in Chiang Mai,Thailand.  Int J Drug Policy 2005, 16:115-121.8. Daosodsai P, Bellis MA, Hughes K, Hughes S, Daosodsai S, Syed Q:Thai War on Drugs: Measuring changes in methampheta-mine and other substance use by school students throughmatched cross sectional surveys.  Addictive Behaviors 2007,32:1733-1739.9. HRW: Thailand: New anti-drug campaign risks abuses.Human Rights Watch; 2008. 10. Small W, Kain S, Laliberte N, Schechter MT, O'Shaughnessy MV, Spit-tal PM: Incarceration, addiction and harm reduction: inmatesexperience injecting drugs in prison.  Subst Use Misuse 2005,40:831.11. Strathdee SA, Zafar T, Brahmbhatt H, Baksh A, ul Hassan S: Rise inneedle sharing among injection drug users in Pakistan duringthe Afghanistan war.  Drug & Alcohol Dependence 2003, 71:17.12. van Griensven F, Pitisuttithum P, Vanichseni S, Wichienkuer P, Tap-pero JW, Sangkum U, Kitayaporn D, Phasithipol B, Orelind K, Choo-panya K: Trends in the injection of midazolam and otherdrugs and needle sharing among injection drug usersenrolled in the AIDSVAX B/E HIV-1 vaccine trial in Bang-kok, Thailand.  Int J Drug Policy 2005, 16:171-175.13. Wattana W, van Griensven F, Rhucharoenpornpanich O, Manopai-boon C, Thienkrua W, Bannatham R, Fox K, Mock PA, Tappero JW,Levine WC: Respondent-driven sampling to assess character-istics and estimate the number of injection drug users inBangkok, Thailand.  Drug Alc Depend 2007, 90:228-233.yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 5 of 5(page number not for citation purposes)

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