1.1.2 Methadone is a synthetic opioid which was first synthesized in Germany in 1941 during World War II as an alternative to morphine for the relief of pain. It was first used as maintenance treatment for heroin dependence in New York in 1964, and has since become one of the most widely used drugs for opiate treatment world-wide. Before methadone maintenance treatment was developed in 1964, methadone was used primarily in the treatment of addiction to withdraw drug dependent persons from heroin (or detoxification), a short-term procedure that exploits only some of methadone’s potentially useful properties. Methadone maintenance treatment, on the other hand, involves administering a constant, therapeutic daily dose of methadone after an initial period of stabilization, concomitantly with medical, rehabilitation, and counselling services.

1.2.1 The objective of the Review was to evaluate the usefulness and effectiveness of MTP, to identify any areas for improvement, and to consider whether there are other alternatives to methadone in drug detoxification and maintenance.

1.3.1 The scope of the Review covered the following aspects :

1.4.1.1 A Working Group on Review of MTP, which was led by Dr. Choi Yuen-wan and comprised 17 Members, was set up in summer 1999 to conduct the Review. The Working Group was also supported by Professor Catherine Tang from the Department of Psychology, the Chinese University of Hong Kong, and representatives of the Narcotics Division and Department of Health. Membership of the Working Group and its terms of reference are at Annexes I and II respectively.

1.4.1.2 There were two Sub-groups under the Working Group, namely Sub-group on Maintenance and Sub-group on Detoxification. Membership of these Sub-groups and their terms of reference are at Annexes III and IV respectively.

1.4.1.3 In October 1999, an ad hoc working group was also established to look into the design and implementation of focus group study relating to MTP Review. Membership of the ad hoc working group and its terms of reference are at Annexes V and VI respectively.

1.4.1.4 From May 1999 to December 2000, the Working Group and its sub-groups had met 13 times. Visits had also been arranged for Members to three methadone clinics, including the Eastern Street Methadone Clinic, Sham Shui Po Methadone Clinic and Shek Kip Mei Methadone Clinic.

1.4.2.3 Survey for measuring community satisfaction with Government’s performance

1.4.2.4 Past research related to methadone treatment programme

1.4.2.5 Application of methadone in other countries/territories

1.4.2.6 Application of new drugs as substitute/supplement to methadone in overseas countries

1.5.1 In December 2000, the Working Group completed its research including literature review, the updating exercise on the profile of methadone patients and focus group studies. Three broad directions are arrived at :

Findings of the Review in support of the above and recommendations by the Working Group are fully described in the following nine chapters.

2.2.1 The objectives of MTP, at the time of this review, were as follows :

2.3.1 Admission “criteria” and assessment

Patients should be involved in developing their personal treatment plans.

2.3.2.1 At the time of the Review, there were altogether 21 methadone clinics, four on Hong Kong Island, ten in Kowloon and seven in New Territories. A map showing the location of the clinics is at Annex XI.

2.3.3 Opening hours

2.4.2.1 In 1999, 101 patients were detoxified. As at end of December 1999, 156 patients were enrolled in the detoxification programme and 96 patients were undergoing the 18-month aftercare period.

2.5.1 In respect of publicity, existing means of promoting MTP include :

2.5.2 The Working Group noted that the existing publicity means are rather limited and was of the view that consideration should be given to producing a new series of information materials to aid educational and publicity efforts. Launching of a professional media campaign with celebrity endorsement should also be explored.

2.6.3.1 Amongst those who were aware of the establishment of MTP, about three-quarters perceived detoxification to be the purpose of MTP and over half (54.3%) thought that it was for maintenance treatment. Less than 5% of them did not know the purpose of MTP.

2.6.5 Satisfaction with Government’s performance on measures of establishing MTP

2.6.5.2 On the contrary, a slightly small percentage (22.0%) of respondents expressed dissatisfaction with the performance of Government in this respect within this group of people. “The programme cannot help drug dependent persons in detoxification” (80.9%) was the most common reason for their dissatisfaction with Government’s performance on this measure over the last 12 months.

2.6.6 Though not conclusive, the result of the survey provided a good indicator as to how perception of methadone can be improved. Having regard to the above observations, the Working Group had the following assessment :

2.7.1 Support from MTP staff and adequate training are key to the success of MTP. The focus group study conducted in support of this Review gauged existing staff perception on MTP. As for training, AMS staff should have passed the annual proficiency examination, attended standard regular AMS training, and special MTP Induction Training course, with both theory and practical attachments, before they were recruited to man the methadone clinics. Medical officers deployed to MTP clinics are experienced practitioners who receive periodic on-going training as continuous improvement to their career. An annual workshop for staff of methadone clinics had been held since 1996 for the medical officers, social workers, and AMS Supervising Officers. Starting from December 2000, AMS members (i.e. dispensing staff) would also be invited to attend the workshop. The focus group study, in support of this Review also gleaned staff’s views on the training needs in support of MTP. The salient findings of such study are appended below.

MTP was generally regarded by staff as more useful for maintenance purpose than for detoxification, though, some felt that the detoxification function should not be undermined because there had been successful cases of detoxification. Clients with high motivation to detoxify would more likely to achieve a successful outcome.

Some staff pointed out that when the dosage was reduced, the change of colour of the present green liquid would be noticeable. This sometimes made it difficult to reduce the dosage for some clients without their knowledge, as they would be sharp to notice the difference in colour. These clients would complain about the reduction of dosage.

Care and encouragement from staff were considered very important to the clients in establishing a good relationship with them. It was noted that although the number of successful detoxification cases was not high, the psychological reward of staff was tremendous when a client successfully achieved detoxification.

The opening hours of clinics should be extended. This would benefit more users and enable the work of the staff to be more spread out.

Staff generally considered it necessary to provide more training for staff, especially more junior ones, on the dispensing of methadone. Having a sufficient level of knowledge of the drugs concerned was important, as medical practitioners did not come to clinics everyday.

Staff strongly considered it necessary to have more sharing of experiences in the form of workshop, for example, amongst all levels of MTP staff. It was considered more appropriate to organize such sharing session twice a year, and that staff of all levels should be invited.

2.7.2 The Working Group considered that the above findings highlight several areas for improvement :

2.7.2.1 Treatment settingImprovement of clinics’ physical setting is required in order to cater for improved “care services”. Consideration should be given to providing facilities like i.e. dedicated rooms for counselling services, information corner, and health education rooms, etc in methadone clinics so that such clinics can be better equipped to provide counselling services, support group activities, public health education programmes, etc.

The opening hours of clinics and the existing treatment protocol should continue to be reviewed periodically having regard to staff and clients’ feedback. The use of existing patient cards should be replaced by personal ID cards.

It is considered that more sharing sessions should be held amongst staff and staff views to improve service delivery should be solicited. Staff training and retraining under MTP should be strengthened to cater for various new initiatives.

The drug abuse trend as at the first half of 2000 is summarized as follows :

3.2.1 The updating exercise mentioned in 1.4.2.1 was conducted in 1999 using 1998 data, including the overall number and characteristics of drug dependent persons in Hong Kong at that time. As a background to this exercise, the 1998 drug abuse situation is summarized below :

3.2.2.1 In 1998, a total of 16 964 drug dependent persons were reported to the CRDA representing a decrease of 3.8% when compared with 17 634 in 1997. The number of Hong Kong drug dependent persons has remained relatively stable over the past four years. The 1998 figure represented a decrease of 16.5% when compared with the figure of 20 327 in 1994.

3.2.2.2 The upward trend of drug abuse amongst young people observed in the early 1990s has been reversed since 1995. In 1998, there were 2 829 drug dependent persons under the age of 21 reported to the CRDA, representing a decrease of 10.2% when compared with 3 149 in 1997.

3.2.2.4 Heroin continued to be the predominant drug of abuse. In 1998, of the 15 720 drug dependent persons reported to the CRDA with types of drug abused provided, 86.3% were known to have abused heroin. Other commonly abused drugs were cannabis (8.9%), amphetamines (6.5%), triazolam (4.8%) and cough medicine (1.8%). The proportion of psychotropic substance dependent persons increased from 21.1% in 1997 to 21.7% in 1998.

3.2.2.5 Of particular concern was the increase in the numbers of reported drug dependent persons who have taken cannabis and methylamphetamine, commonly known as “ice”. Reported drug dependent persons on cannabis rose by 5.8% from 1 325 in 1997 to 1 402 in 1998; while those on “ice” rose from 839 to 937 in the corresponding period, an increase of 11.7%.

3.2.3.1 Of the 16 964 drug dependent persons reported in 1998, 87.3% were men and 12.7% were women. 16.7% were aged under 21 and 83.3% 21 and above. Comparing the age distributions of the two sexes, it was noted that the females recorded a higher percentage in the younger group, with 32.9% being under 21 as compared with 14.3% for males.

3.2.4.1 Of the 16 388 drug dependent persons reported to the CRDA in 1998 with their district of residence reported, those living in Kwun Tong constituted the largest proportion (11.3%), followed by Sham Shui Po (9.6%) and Yau Tsim Mong (8.9%). Amongst those aged under 21, 12.3% lived in Tai Po, 11.8% in Tuen Mun and 9.1% in North.

3.2.5.2 Heroin abuse was also very significant amongst young persons aged under 21, with 58.3% of the 2 539 youngsters reported to have abused heroin in 1998. The abuse of cannabis (26.7%), amphetamines (19.5%) and triazolam (1.8%) was also very popular amongst young persons.

3.2.6.1 Of those drug dependent persons who provided information on the age of first drug abuse in 1998, 67.2% claimed to have started drug abuse at the age between 15 and 24. 20.4% under 15, and the remaining 12.5% over 24. The mean age of first abuse of all drug dependent persons was 18.5, with females starting drug abuse slightly earlier, at 17.9 compared with 18.6 for males.

3.2.7 Reason for current drug abuse

3.2.7.1 Of the 14 710 drug dependent persons reported to the CRDA in 1998 who gave reasons for current drug abuse, 51.5% took drugs to avoid discomfort of its absence, 31.1% under peer influence, 29.2% for curiosity and 23.1% to relieve boredom. Amongst those young drug dependent persons aged under 21, their main reasons for current drug abuse were under peer influence (60.6%), for curiosity (38.6%), to avoid discomfort of its absence (30.5%) and to relieve boredom (27.2%).

3.2.8 Usual daily expenditure on drug

3.2.8.1 The average daily expenditure of the 12 842 drug dependent persons in 1998 who gave information on expenditure on drugs was $254. The 21-and-over group spent more money on drugs than the under-21 group. The average usual daily expenditure for the former was $265 while that for the latter was $178.

From the updating exercise conducted in 1999, major observations from the data about profile and characteristics of methadone patients are set out below.

3.3.1 Personal and drug abuse characteristics

3.3.1.2.1 88.0% of the methadone patients admitted in 1998 were male, compared with 95.0% for SARDA, 94.7% for DATCs and 86.4% for religious treatment programmes.

3.3.1.2.2 Analyzed by age group, MTP, SARDA and DATCs had the majority of drug dependent persons admitted in age bracket of 21 to 50, while the religious treatment programmes had the majority of their admitted drug dependent persons between 16 to 40. Compared the mean age of the drug dependent persons admitted to the various treatment programmes, the youngest was found in the religious treatment programmes, followed by DATCs, MTP and SARDA.

3.3.1.4.1 The drug dependent persons admitted to the religious treatment programmes received comparatively more education, with about 75% attaining lower secondary or above standard. The corresponding percentage for the other three groups was only about 55%.

3.3.1.5.1 The percentage distributions in the type of living quarters were similar for the four groups of drug dependent persons. The majority of the drug dependent persons (55.8% to 60.7%) were found to live in public and aided rental blocks, followed by private housing (25.2% to 30.9%) and other housing (7.4% to 11.1%).

3.3.1.6 Employment status

3.3.1.6.1 The drug dependent persons admitted to MTP and SARDA in 1998 exhibited similar percentage distribution in their employment status, with the majority (over 55%) of them were unemployed. While 51.9% of drug dependent persons admitted to DATCs were employed, either as full-time workers or casual/part-time workers, compared with 48.4% for religious treatment programmes, 38.5% for MTP and 38.4% for SARDA.

3.3.1.7 Previous conviction

3.3.1.7.1 Over 80% of the drug dependent persons admitted to the various treatment programmes had previous conviction history. Drug dependent persons were more commonly involved in both drug-related and other offences. But the proportion of drug dependent persons admitted to DATCs (72.8%) having previous convictions on both drugs related and other offences was much higher than those for the other three treatment programmes, ranging from 35.3% to 45.3%.

3.3.1.8 Major reasons for current drug use

3.3.1.8.1 Drug dependent persons admitted to MTP, SARDA and DATCs claimed to avoid discomfort of the absence of drug and peer influence as the two major reasons for current drug use. While for those admitted to religious treatment programmes, their two main reasons reported were peer influence and curiosity.

3.3.1.9 Type of drug abused

3.3.1.9.1 Heroin was the predominant drug of abuse reported, ranging from 94.4% to 99.7% for the four categories. Amongst them, drug dependent persons admitted to the religious treatment programmes were reported at a greater proportion (3.2%) to abuse cough medicine.

3.3.1.10 Duration of drug use

3.3.1.10.1 The drug dependent persons admitted to religious treatment programmes had the shortest drug use history, with less than 45% have abused drug for more than ten years, in comparison with 61.4% to 73.8% for the other three groups.

3.3.2 Admission Pattern

3.3.2.1 Time since first registered to MTP

3.2.2.1.1 Of the 7　.1 Of the 7　669 drug dependent persons admitted to MTP in 1998, 28.6% had been registered in the programmes for 10 - 19 years, and about 18.8% for 20 years or more. The mean time lag since first registered to MTP was about 11 year

3.3.2.2 Number of previous admissions

3.3.2.2.1 About two-fifths of the methadone patients admitted in 1998 had one to four previous admissions, and about a quarter had five to nine previous admissions. About 9% of the 7　3.3.2.2.1 About two-fifths of the methadone patients admitted in 1998 had one to four previous admissions, and about a quarter had five to nine previous admissions. About 9% of the 7　669 drug dependent persons in 1998 had 15 or morerevious admissions. The other 14.3% of methadone patients were newly registered with no readmission. The mean number of previous admissions was seven.

3.3.2.3 Average time lag between admissions

3.3.2.3.1 The average time lag between all the admissions of each patient was computed and it was noted that methadone patients tended to be readmitted within a short interval. On average, about 38% of the 7　of each patient was computed and it was noted that methadone patients tended to be readmitted within a short interval. On average, about 38% of the 7　669 methadone patients in 1998 had been readmitted within one to two years and about 20% less than oneear.

3.3.2.4 Time lag between the last two admissions

3.3.2.4.1 The time lag between last admission and current readmission was very short. About 38% of the methadone patients were readmitted within one year from their last admission and about 22% within one to two years.

3.3.3 Reporting history to CRDA

3.3.3.1 Reporting agencies ever contacted before first admission

3.3.3.1.1 The reporting agencies ever contacted by 3　3.3.3.1.1 The reporting agencies ever contacted by 3　835 methadone patients before their first admission were studied. It was notedhat the Police (82.3%) was the major reporting agency before their first admission to MTP, followed by CSD (41.8%) and SARDA (15.1%).

3.3.3.2 Treatment agencies ever contacted before first admission

3.3.3.2.1 Amongst the 1　3.3.3.2.1 Amongst the 1　806 methadone patients whoad previously approached other treatment agencies, the DATCs and SARDA were the two major treatment agencies that these methadone patients approached before seeking treatment from MTP. These were followed by the Wu Oi Christian Centre (9.0%) and the Society for the Rehabilitation of Offenders, Hong Kong (SRO) (7.6%).

3.3.3.3 Treatment agency ever contacted immediately before and immediately after first admission

3.3.3.3.1 The major treatment agencies that the methadone patients most commonly contacted immediately before first admission to MTP were DATCs (54.7%), SARDA (26.0%), Wu Oi Christian Centre (5.5%) and SRO (5.4%). While after first admission, the treatment agency that they immediately contacted was in the same order, DATCs (48.4%), SARDA (37.7%), Wu Oi Christian Centre (4.2%) and SRO (2.7%).

3.3.3.4 Maximum number of reporting agencies and treatment agencies contacted in between each admission and readmission

3.3.3.4.1 Of the 7　3.3.3.4.1 Of the 7　669 methadone patients in 1998, most methadone patients had contacd two reporting agencies (30.5%) and one treatment agency (38.5%) in between each admission and readmission. However, it was noted that 11.3% and 19.9% of them respectively had not contacted any reporting agencies and any treatment agencies in this respect. On the other hand, it was noted that, at maximum, about 8% had contacted four or more reporting agencies and about 6% had contacted three or more treatment agencies in between one admission and readmission.

3.3.3.5 Number of treatment agencies ever contacted by length in Methadone Patients Registry

3.3.3.5.1 The number of treatment agencies ever contacted since first registration tended to increase with length in the Methadone Patients Registry. For those in the Registry of less than ten years, the majority had ever contacted one treatment agency, while for those in the Registry of ten years or more, the majority had at least approached two treatment agencies.

Similar study on the profile of methadone patients was conducted in the 1995. The opportunity was taken to make a comparison of the results between these two studies so as to examine whether there would be any significant changes in the characteristics of methadone patients over the past three years. Major observations are set out as follows.

3.4.1.1 There were no significant changes in the methadone patients as to their sex, age, martial status, type of living quarters and type of drug abused over the past three years. When compared with the results in 1995, more methadone patients in 1998 were found to be unemployed (55.8%) and have previous convictions on both drug related and other offences (43.8%).

3.4.1.2 The proportion of methadone patients reported to avoid discomfort of the absence of drug as the major reason for current drug use also increased from 47.7% in 1995 to 68.8% in 1998. Compared the mean duration of drug use between these two periods, methadone patients in 1998 were found to have a slightly longer drug use history (18.1 years) than those admitted in 1995 (17.3 years).

3.4.2.1 The mean time lag since first registered with MTP of methadone patients in 1998 (11.5 years) was found to be slightly longer than those admitted in 1995 (10.9 years). As regards other admission patterns of methadone patients, no significant changes were observed between these two time periods.

3.4.3.1 Except for the number of treatment agencies ever contacted, there were significant changes in their reporting history between 1995 and 1998. Amongst the newly registered cases with no readmission, those admitted in 1998 had a lower proportion (83.1%) of never contacted any treatment agencies since first registration than that (92.0%) in 1995.

From part (ii) of the updating exercise, major observations from the survey of 729 patients interviewed, out of 922 selected patients about the about usefulness and effectiveness of methadone treatment programme are set out in the following paragraphs in two parts, first on the methadone patients’ perception and opinions on MTP; and second on the methadone patients’ changes in characteristics after joining the programme.

3.5.1.1.1 On the question whether they knew that there were other kinds of drug treatment service, about two-thirds of the methadone patients surveyed replied positively. It was noted that the younger the age of the methadone patients, the higher the percentages of them knew that there were other kinds of drug treatment service.

3.5.1.1.2 Detoxification (58.2%) was the most common aspect which methadone patients thought that drug treatment service could help them, followed by maintenance (43.7%) and employment (20.5%).

3.5.1.2.1 Over 55% (or 407) of the methadone patients reported that detoxification was their reason for joining MTP. Amongst them, 93.8% also thought that methadone could be used for detoxification. The other common reasons for joining MTP were for maintenance (28.8%) and to hope to lead a normal life (18.8%).

3.5.1.3.1 The majority (79.5%) of methadone patients expressed satisfaction for the service of the methadone clinic.

3.5.1.3.2 The results also showed that most methadone patients were satisfied with the operation of methadone clinics, in particular their degree of freedom (96.8%), facilities (94.6%), staff attitude (94.1%) and waiting time (93.3%). Despite the above, about a quarter (25.1%) of the methadone patients expressed dissatisfaction on the opening hours of methadone clinic. For those who were dissatisfied with the current methadone dosage, about 50% wanted to decrease the dosage while 40% wanted to increase the dosage.

3.5.1.4.1 On the question of whether there was any room for improvement in clinic environment and facilities, about 80% of the methadone patients replied in the negative.

3.5.1.4.2 For those who considered that there was room for further improvement, more than one third reported that there should be more space for the methadone clinic. Other improvement areas were on the access to the clinic (27.0%) and their cleanliness and tidiness (20.3%).

3.5.1.5.1 When asked whether they know what kinds of use methadone has, more than 90% of the respondents said that it could be used for detoxification. About half of the respondents said methadone could also be used for maintenance.

3.5.1.5.2 Amongst the 68 methadone patients who did not know that methadone could be used for detoxification, about 90% were males and aged 21 and over.

3.5.1.6.1 A great majority (88.9%) of the methadone patients interviewed reported that they had ever considered using methadone for detoxification. This figure also represented 93.6% of those who joined MTP for detoxification. However, they had not yet joined the detoxification programme mainly because they had no time (32.2%) and thought that gradual detoxification could be achieved through the maintenance programme (30.9%). Other reasons include no confidence (12.3%), worried about the discomfort involved (8.6%) and no need (8.4%).

3.5.1.6.2 Amongst those patients who reported that they would not use methadone for detoxification, their most common reasons were no confidence (34.6%) and no time (33.3%). Other reasons include thinking of it being useless (14.8%), worried about the discomfort involved (12.3%) and no need (11.1%).

3.5.2.1.1 The majority (74.0%) of the methadone patients reported that they had improved in spirit after receiving methadone treatment. Compared with male methadone patients, a higher percentage (10.5%) of female patients reported that they had worsened in spirit after receiving methadone treatment.

3.5.2.2.1 Over half (52.1%) of the methadone patients had improved in relationship with family members after receiving methadone treatment. The improvement was particularly significant for young methadone patients (65.4%).

3.5.2.2.2 The results indicate that a higher percentage (55.5%) of patients who had ever received counselling service from SARDA was found to have improvement in relationship with family members after receiving methadone treatment when compared to those who had never received counselling service from SARDA (47.1%).

3.5.2.3 Change in frequency of contact with non-drug dependent friends

3.5.2.3.1 After receiving methadone treatment, about 35.5% of the methadone patients reported that they had made more frequent contacts with their non-drug dependent friends.

3.5.2.7.1 Over 50% of the patients claimed that people committed fewer illegal acts such as thefts and robberies after joining MTP.

3.5.2.7.2 The results of correlation analysis indicate that the average daily attendance of MTP is significantly associated with some crime-related factors. More methadone patients will be expected to receive treatment when there is an increase in the price of heroin or a decrease in reported crimes of minor narcotics offences (such as simple possession of drug abuse equipment and consumption of drugs). Besides, there is also a negative association between the average daily attendance rate and the reported crime rate of thefts.

3.6.1 As the existing counselling services of methadone patients are provided by the social workers of SARDA, a study was conducted on the perceived social needs of methadone patients in Hong Kong amongst 11 social workers.

3.6.3 Content analysis method was applied to analyze the social workers’ responses. From the study, major findings about perceived social needs of methadone patients are summarized as follows :

3.6.4.1 Unemployment and under-employment amongst methadone patients were very common phenomenon. There was also a lack of community resources in helping the clients to settle their unemployment problems since the greater social context was also suffering from economic recession.

3.6.4.2 A number of methadone patients had spent many years in prison. One common problem they encountered in attending job interview was how they could explain their history and the lack of working experience before the prospective employer.

3.6.4.3 A stable employment was considered to be crucial for the maintenance of a heroin-free status.

3.6.5.1 Financial assistance was deemed necessary for patients in methadone maintenance cases who were unable to work due to their physical conditions.

3.6.6.1 As the emotional state of methadone patients tended to fluctuate during the period of detoxification, it was fairly common that they would quarrel with their family members or significant others. In some cases, educating family members about the proper handling of patients during detoxification was useful to rehabilitation. However, in some extreme cases, a temporary shelter in the form of halfway house might be beneficial to the patient concerned.

3.6.7.1 Methadone patients frequently complained that when the Police detected their methadone patient cards in their belongings, the Police tended to treat them as drug dependent persons. They felt a lack of legal protection of being a methadone patient.

3.6.8.1 Family members generally had a negative perception of methadone treatment and did not accept the methadone patients’ identity. They viewed methadone patients as no difference from drug dependent persons. They felt worried that methadone was also addictive drug but they failed to appreciate the harm reduction function of methadone. This perception was mainly affected by some negative reports on methadone by media.

3.6.9.1 Most of the methadone patients had a low self-esteem and kept a distance from their non-drug dependent friends. They usually had a feeling of boredom and re-associated with former drug dependent peers.

3.6.10.1 Methadone patients considered themselves stigmatized, rather than accepted by the general public.

3.6.11.1 Majority of methadone patients had been addicted to drugs for many years, and they had lost their previous interests and hobbies. This led to a feeling of boredom and meaninglessness in leading a heroin-free life. Many clients perceived an increase in leisure time after they started to maintain on or are detoxified using methadone. The lack of leisure and recreational activities was a risk factor for such patients.

3.6.12.1 Methadone patients were reluctant to make friends due to low self-esteem. This source of self-esteem was related to seeing oneself as a useless drug dependent person. The impact was that they did not expand their social network and eventually lead to boredom and re-association with drug dependent friends.

3.6.13.1 Methadone patients were lacking knowledge of self-care. They were in need of knowledge about AIDS prevention, sex education, personal health care, personal hygiene, etc.

3.6.14.1 Methadone patients had medical needs. When they discussed medical problems with methadone medical officers, they were referred to meet general practitioners of the out-patient clinic. However, methadone patients reflected that the out-patient medical officers knew little about methadone and were not sure about whether their illness was related to methadone.

3.7.1 In view of the foregoing findings, the Working Group considered that the following areas should be given due attention for improving MTP.

3.7.2.1 The survey results indicated that a higher percentage (55.5%) of patients who had ever received counselling service from SARDA was found to have improved relationship with family members. This confirmed the importance of counselling and the Working Group’s proposed emphasis on counselling services to patients of all ages and background while maintaining a distinctively intensive approach for the young.

3.7.2.2 From the survey finding, it was noted that amongst those methadone patients who reported that they had still abused heroin, the reasons were inner craving (58.9%) and under the influence of drug dependent friends (15.1%) (3.5.2.5.2). In order to counter the influence of drug dependent peers, formation of support group for patients undergoing detoxification should be considered. This would enable patients to gain mutual support from amongst those having a similar background. This can also help to address the findings of the perceived social need of belongings and love from peers (3.6.9.1).

3.7.3.1 From the result of the survey, it is apparent that a stable employment was considered as crucial for the maintenance of a heroin-free status. A gainful employment not only fulfills one’s financial needs, it also increases one’s self-esteem, lessens the feeling of boredom and gives a sense of purpose. It is therefore considered necessary to strengthen services in support of vocational training for methadone patients. Employment, vocational or social skill training for methadone patients might be strengthen through enhanced linkage between MTP and other social employment services. Such services might also be provided through referral of patients to reasonably accessible community resources, vocational rehabilitation, education and employment services. This could be pursued in collaboration with Government departments and various NGOs.

3.7.3.2 From the survey, it was noted that over 55% of the methadone patients interviewed reported that detoxification was their reason for joining MTP (3.5.1.2.1). Further, 88.9% of methadone patients in the survey said they had considered using methadone for detoxification. (3.5.1.6.1). Having regard to these findings, consideration should be given to referring, where appropriate, this group of patients who want to undergo detoxification to join residential detoxification programmes with aftercare offered by non-government organizations.

3.7.4.1 As suggested in 3.7.2.2, support groups should be formed to better assist patients and their families.

3.7.5.1 To enhance the administrative efficiency of MTP, the operation of methadone clinics should be computerized, by phase and having regard to the availability of resources. The existing manual data management system should be replaced, in the long term, to release capacity of staff for supporting improvement measures and initiatives under MTP.

3.7.5.2 Having regard to the long term prospect of computerizing the operation of MTP, consideration should be given to ultimately replacing the use of existing patient cards by personal ID cards and streamlining procedures for patient transfer upon change of patients’ addresses.

3.7.6 Staff education and training

3.7.6.1 Dedicated forums for social workers might be conducted with assistance from the Society for the Aid and Rehabilitation of Drug Abusers (SARDA) and the Hong Kong Council of Social Service (HKCSS) to orientate workers towards attitude change to methadone patients, and to align them with the objectives of the changes/initiatives introduced/being contemplated for MTP.

3.7.6.2 Tailor-made educational kit or other aids for use in staff induction and retraining courses should be developed. The enhancement of recruiting and training families and peer counsellors should be considered.

3.7.7.1 The public health functions of MTP should be given due emphasis in all publicity. Some methadone patients did not join the detoxification programme because they thought that detoxification could be achieved through the maintenance programme and they were worried about the discomfort involved (3.5.1.6.2). Such findings reflected that not all MTP patients had an adequate understanding about the programme itself and more needs to be done to introduce the objectives of the programme and what it has to offer.

3.7.7.2 These observations together with those set out in 2.6.6 call for an overall publicity programme to enhance the understanding of both public and methadone patients on the use and nature of MTP. Target of education should include not just existing patients but also staff and the public at large. A structured publicity strategy targeting district organizations should also be drawn up.

3.8.1 Findings of the usefulness and effectiveness of MTP affirm the need to continue with MTP. Having regard to the profile and social needs of the methadone patients, the Review reflects that further improvement to support services provided for MTP patients should warrant special attention. Such services include three main streams of services : counselling, referral as well as support groups. In addition, ways to streamline the existing operation of the clinics should be considered, and staff training should be strengthened. Employment of more peer counsellors in support of MTP patients and enhancing publicity on MTP should be considered.

4.3.3.1 Reduction of the social cost of loss of productivity

4.3.3.1.1 A loss of productivity, which is an indirect and tangible social cost, occurs when a member of the society at a working age becomes unable to participate in the work force due to his/her drug abuse. The finding of the survey of MTP patients as reported earlier (3.5.2.4.1) shows that amongst these subjects, there was an increase of 4.6% of them who were able to have a full-time or part-time employment after joining MTP. Since the daily attendance of MTP clinics for the year 1998 was 6 691 (this number is more preferable than the total annual admission number), the number of MTP patients whose employment could be attributed to MTP in 1998 was 6 691 x 4.6% = 308. In the above-mentioned report of the social costs of drug abuse study, the average monthly income used to calculate loss of productivity in 1998 was $8,508. Therefore, the social cost of loss of productivity that had been saved or reduced in 1998 due to the utilization of MTP was 308 x $8,508 x 12 months = $31.45 million.

4.3.3.1.2 In the report of the social costs of drug abuse study, the total amount of loss of productivity in 1998 was estimated to be $753.88 million. If MTP had not contributed to the reduction of this social cost, its amount would have been $753.88 + $31.45 million = $785.33 million.

4.3.3.2 Reduction of the social cost of petty and property crimes

4.3.3.2.1 To most drug dependent persons, committing theft and other property crimes is a significant means of obtaining money needed to sustain their expensive drug abuse behaviour. The value of the item involved in such a crime is an indirect and tangible social cost. In the report of the social costs of drug abuse study, it was estimated that the value of things involved in theft and other property crimes committed by a drug dependent person in 1998 was $5,000 per month. MTP patients who were not using heroin at the same time would not need to commit petty crimes for money, and those MTP patients who concomitantly used methadone and heroin would commit property crimes at half of the value of property crimes committed by a regular drug dependent person (i.e., $2,500 per month). It was further assumed that half of MTP patients would be double users. Using the daily attendance of MTP clinics figure of 6 691, the social cost of petty and property crimes that had been saved or reduced in 1998 due to MTP was 6 691 ÷ 2 x ($5,000 + $2,500) x 12 = $301.1 million.

4.3.3.2.2 In the report of the social costs of drug abuse study, the total value of items involved in property crimes committed by all drug dependent persons in 1998 was estimated to be $595.41 million. If MTP had not contributed to the reduction of this social cost, its amount would have been $595.41 + $301.1 million = $896.51 million.

5.1.1 The Review had studied several drugs, including buprenorphine, levo-a -acetylmethadol (LAAM), some Chinese medicine and naltrexone. Detailed observations are appended below.

5.2.1 Buprenorphine is a mixed opioid agonist and antagonist. It is given by sublingual route. At low dose, it serves as an agonist while at higher dose, its antagonist action manifests and can precipitate withdrawal symptoms from opiate dependent persons, methadone or LAAM clients. It tightly binds to receptors and thus has a long duration of action. On cessation of treatment, withdrawal symptoms are said to be mild.

5.2.2 A number of studies (particularly in the US) suggested that the drug could be useful as an alternative maintenance agent to methadone for those with lower levels of opiate dependence in the context of a well-supervised and monitored programme. While the drug is licensed in UK, it has not been investigated seriously as a maintenance agent to date. Buprenorphine has also been registered for similar use in France, Switzerland and Finland. It is also noted that trials have been undertaken in China. In the US, the drug has been designated Orphan Drug Status in 1994 for the treatment of opiate addiction, but is not yet approved by US Food and Drug Administration under new drug application.

5.2.3 Although the drug has yet to be seriously studied for its efficacy in reducing opiate use, there are some studies in US, Europe and China to support that the drug is efficacious for maintenance and detoxification, and a dose-response relationship is identified. Buprenorphine has the advantages of causing lower level of dependence and minimal withdrawal symptoms, and possibility of longer intervals between administrations. However, the Working Group noted that its superiority over methadone is still inconclusive in the available comparative studies findings.

5.3.1 LAAM is a synthetic opioid agonist. It was approved for treatment of opiate addiction in the US in 1993. It has a very long duration of action of 48 to 72 hours (range for methadone is 24 to 36 hours). This can allow LAAM treatment to be given every other day.

5.3.2 As for effectiveness, some studies showed a dose-response relationship between LAAM administration and reduction in opiate use. However, there is no convincing evidence to suggest that it is superior to methadone. A meta-analysis by Harvard School of Public Health on the reported randomized, controlled trials comparing LAAM and methadone found a statistically significant difference favouring methadone in retaining clients in treatment programmes. At the same review, some difference was observed favouring LAAM in reducing illicit opiate use but the finding was not statistically significant. Other reports also quoted the retention problem of LAAM programmes as some drug dependent persons consider that LAAM has “no feel”, and tend to switch back to other maintenance treatment. The experience of LAAM for detoxification is also limited.

5.3.3 With regard to safety, the drug is safe when used properly. The common side effects include insomnia, nervousness and constipation. The safety concern of LAAM lies in its long- acting property. The drug dependent persons have to be warned that peak activity of LAAM is not immediate, and that concomitant use of other psychoactive drugs, including opiates or alcohol, may result in combined overdose and death. In fact, deaths due to this reason have been reported. Overdose could also occur if the drug is administered daily. Therefore, the drug is not recommended to be administered daily or methadone should be added as supplement. In the US, home treatment with LAAM is not allowed for safety reasons. In summary, monitoring and user education is very important to ensure user safety.

5.3.4 Being an opioid agonist, LAAM also creates some degree of iatrogenic dependence like methadone and buprenorphine. Its severity of withdrawal symptoms is similar to methadone.

5.3.5 In general, neither buprenorphine nor LAAM is exempted from most of the limitations of methadone. Studies on the former two drugs are comparatively small in scale and limited in number when compared to methadone studies. These studies were also confined to assessing their efficacy in reducing illicit opiate use but did not address other aspects like reduction of criminal activities, decreasing risk of related infectious diseases and deaths. Both of them are addictive drugs although buprenorphine is noted to be less addictive.

5.3.6 While the pharmacological properties of buprenorphine suggest that it is potentially superior to methadone, studies so far have not yet demonstrated its superiority over methadone in the practical clinical setting. Concern on its potential to be abused through injection, which could result in severe complications and deaths as experienced in overseas countries, should also be noted.

5.3.7 Similarly, there is no convincing evidence to suggest that LAAM is more superior to methadone. Based on the studies on LAAM, its advantage of having longer action and allowing alternative day treatment is compromised by its problems in client retention and the potential lethal side effects of combined drug overdose. Given a significant number of opiate dependent persons patronizing maintenance programmes also practise opiate use, the potential risk should not be underestimated.

5.4.1 In China, there were five Chinese medicine awarded the “Permission for Production of New Drug” by the State Drug Administration of the Mainland as at August 1999. “Fukang Tablet” is one of the five such medicine.

5.4.2 “Fukang Tablet”

5.4.2.2 According to the Titan Enterprise (China) Limited, the sole agent of “Fukang Tablet”, the drug took six days for patients to be completely detoxified. Drug intake was three times a day and four tablets each time. For the whole course of treatment, a patient took a total of 72 tablets.

5.4.2.3 Regarding relapse prevention, a research study had been conducted for 100 drug dependent persons. Amongst them, 36 relapsed after being detoxified for six months, though it has to be noted that relapse can be due to a host of factors including social and economical factors, apart from medical ones.

5.4.2.4 As at August 1999, the market price of the drug in Hong Kong was $4,800 per course of treatment. For exporting to overseas countries, the selling price was around US $400 - 500.

5.4.2.5 It does not appear practicable to conclude at this stage whether “Fukang Tablet” was significantly superior than other Chinese medicine for the purpose of detoxification. The Working group is of the view that formal clinical trial or use of Chinese medicine in drug treatment and rehabilitation should tie in with the full commencement of the Chinese Medicine Ordinance (Cap. 549). The Ordinance provides a statutory framework to license practitioners and regulate Chinese medicines. The Chinese Medicine Bill introduced into the Legislative Council in February 1999 turned into an Ordinance in July 1999. It is expected that regulation of Chinese medicine will be implemented by phases starting 2001. The Working Group considered that when in full operation, the Ordinance will provide the necessary framework for full-fledged clinical trials of Chinese medicine for detoxification and relapse prevention to begin.

5.5.1 The Drug

5.5.1.1 Naltrexone is an opiate antagonist which blocks the subjective and physiological effects of morphine and heroin. It has long acting effect and being well absorbed when given by mouth. It is useful only for acute reversal of opiate effects as in the emergency treatment of opiate overdoses and the diagnosis of physical dependence. Naltrexone, when given within a structured rehabilitation programme, appears to be effective, particularly with specific motivated populations, e.g. prisoners on probation, employed individuals, those having a stable relationship with non-addicted spouses or family members, and health care professionals who are drug dependent persons.

5.5.1.2 Pharmacological properties

5.5.1.2.1 Naltrexone is extensively metabolized in the liver. It has a plasma half-life of four hours. However, its active metabolite, 6-a -Naltrexol has a plasma half-life of 12 hours. The pharmacological duration is actually longer with antagonism of injected opiates up to 72 hours after a 150 mg dose.

5.5.1.2.2 Although daily ingestion would provide the most secure protection against opiate effects, it can be given as infrequently as two to three times per week, with adequate protection against re-addiction.

5.5.1.2.3 Tolerance does not appear to develop to the antagonism of opiate effects. There is no dependence on naltrexone and in-take of the drug can be stopped abruptly at any time without concern about withdrawal symptoms.

5.5.1.2.4 Opiate dependent patients should be opiate-free for seven to ten days before receiving naltrexone. A naloxone challenge test is recommended.

5.5.1.2.5 At usual therapeutic doses the adverse effects are usually transient and mild. Some may be associated with opiate withdrawal. Difficulties in sleeping, loss of energy, anxiety, dysphoria, abdominal pain, nausea, vomiting, reduced appetite, joint and muscle pain, headache may occur.

5.5.1.2.6 Patients must be counselled and warned that attempts to overcome the opiate blockade with large doses of opiate could result in fatal opiate intoxication.

5.5.1.3 Efficacy of naltrexone

5.5.1.3.1 Naltrexone can permit recently detoxified drug dependent patients to return to their usual environments secure in the knowledge that they cannot succumb to an impulsive wish to get high. His opiate-free period permits the use of community rehabilitation and counselling to deal with underlying or superimposed psychosocial problems.

5.5.1.3.2 For quite a number of opiate dependent persons, after detoxification, the subtle manifestations of the opiate withdrawal syndrome known as “Protracted Withdrawal Syndrome”, which can last for six months or more, makes the patient’s autonomic nervous system unstable. Symptoms such as anxiety and sleep disturbance are common. Conditioned response to environmental cues produced by previous use may also contribute to relapse. Maintenance on naltrexone provides an ideal situation to extinguish these conditioned responses and permit the protracted withdrawal syndrome to subside.

5.5.2 Use of naltrexone in Hong Kong and other countries

5.5.2.1 Castle Peak Hospital’s experience

5.5.2.1.1 Naltrexone was used in the Castle Peak Hospital since May 1996. Initially, naltrexone was intended for use only with the “Clonidine and Naltrexone Rapid Detoxification Programme” in the in-patient service for the opiate (heroin and/or methadone) dependent persons. In view of its usefulness in relapse prevention for motivated drug dependent persons, naltrexone was then introduced into the programme after detoxification was completed.

5.5.2.1.2 According to the Castle Peak Hospital, in all cases, it was important to be certain that there was no residual dependence on opiates, which might require seven to ten days after the last dose of opiates before initiating treatment with naltrexone. Naltrexone challenge test was necessary, except for cases which have been detoxified with clonidine and naltrexone rapid detoxification programme.

5.5.2.1.3 In Castle Peak Hospital, not all cases completing detoxification were recommended for naltrexone maintenance. Only the patients who were motivated and whose significant figures in the patient’s life, e.g. non-drug dependent spouse or parents, who could be involved to observe the ingestion of naltrexone and to report periodically to the therapist are selected. It was important to recognize that ingestion of naltrexone be monitored rather than left to the patient’s willpower. Although the patients were advised to continue with treatment for at least three months, they were told that naltrexone can be terminated at any time, as it was voluntary in nature. Progress in treatment was determined by engagement in regular follow-up when supportive counselling was provided, and absence of drug abuse as confirmed by urine tests. A “slip” was not treated as a failure of treatment, but rather as a symptom to be examined in therapy.

5.5.2.1.4 A brief review was made in the outcome of the cases given naltrexone maintenance from 1 May 1996 to 31 March 1999. There was a total of 24 trials of naltrexone maintenance, with 22 cases (two cases had repeated trials within the period). The outcome review was made in the period from 11 October 1999 to 15 November 1999, when the patients were contacted over the phone. The outcome domains covered three areas, i.e. drug misuse, physical health, and social functioning including criminal activity, family relationship and employment status.

5.5.2.1.5 The Working group noted that it was difficult to draw any meaningful conclusion from the outcome study with such a small sample size. Retention rate and abstinence rate after six months were the two often quoted outcome data in similar studies. Although all patients entering the naltrexone maintenance programme had asserted strongly that they wanted to give up drugs, they might not have really thought through the consequences of their statements. Once they found themselves on a medication that made it physically impossible for them to get high on heroin, they often changed their minds. This outcome study showed a wide range of period when patients had stayed on with naltrexone.

5.5.2.1.6 All 24 trials had naltrexone maintenance terminated already at the date of outcome assessment. The Working Group noted that only eight out of the 24 trials had maintenance period of 30 days or more (33%). Of these eight, only four had completed maintenance of 90 days (17%). Ten trials had been terminated after ten days or less (42%). If 90 days were regarded as the maintenance period aimed at, the successful retention rate was only 17%. The 83% of dropout rate was higher than the 65% dropout rate of the US National Institute on Drug Abuse (NIDA) funded studies of naltrexone.

5.5.2.1.7 Of the four cases which succeeded to maintain on naltrexone for 90 days and more, three were abstinent according to the present outcome assessment. The successful abstinent rate is 75%, higher as compared to the group’s overall abstinent rate of 41%. This appears to confirm the consensus agreement that those willing to remain on naltrexone for three months or more generally do well.

5.5.2.1.8 The Castle Peak Hospital viewed the overall abstinence rate of 41% as encouraging, though it was difficult for the Hospital to know to what degree the success is influenced by the patients’ strong motivation as evidenced by remaining in treatment, or to the other intervening factors in the period after the maintenance treatment to the date of outcome assessment, e.g. the provision of service from a highly motivated and trained staff, community and patients’ families support, steady job, etc.

5.5.2.2 Singapore’s experience

5.5.2.2.1 The Working Group noted that in Singapore, a pilot programme using naltrexone was launched by the Prisons Department in August 1993. Since June 1995, naltrexone has been incorporated into mainstream community rehabilitation programmes.

5.5.2.2.2 Operationally, ex-drug dependent persons on naltrexone treatment are managed in an out-patient setting. They return three times a week for a year to designated centres where the drug is dispensed. Medical consultation and counselling services are readily accessible upon request.

5.5.2.2.3 Naltrexone treatment is now also available at private clinics and Singapore’s Government polyclinics. This increases the number of avenues for drug dependent persons to come forward for treatment.

5.5.2.2.4 Naltrexone was incorporated into Community-Based Rehabilitation (CBR) in the Halfway House (HWH) Scheme and the Residential Scheme in June 1995. Drug inmates selected for CBR have the additional option of being placed in naltrexone treatment while being put on the HWH Scheme or Residential Scheme.

5.5.3 Criteria for patients undergoing naltrexone treatment

5.5.3.1 Having regard to the experience of the Castle Peak Hospital, the Working Group was of the view that only patients with high motivation and family support are suitable for using naltrexone to prevent relapse, should naltrexone be widely and officially applied in Hong Kong. Given that naltrexone was well-tested in Singapore and to a limited extent, locally, consideration should be given to launching a clinical trial of this drug in Hong Kong. Consideration should also be given to adopting the following criteria for patients undergoing trial of naltrexone treatment in Hong Kong :

5.5.3.2 Absolute criteria

5.5.3.2.1 This set of criteria is absolute and should be strictly applied in the selection of suitable clients and excluding the opiate dependent persons who would be at risk (physical or psychiatric) if given the naltrexone treatment.

5.5.3.2.2 Having been fully informed of the particulars of the treatment process and implications, patients should give full consent to treatment. Apart from the use of naltrexone, patients should agree on entering a structured psychosocial programme which aims at rehabilitation and recovery from opiate addiction. This includes regular follow-up at the clinic, regular counselling and random urinalysis. This treatment should continue for a period of at least three months, but preferably six months or more.

5.5.3.2.3 Patients should be detoxified from opiate, i.e. opiate-free for seven to ten days (at least seven days for heroin and ten days for methadone). A naltrexone challenge test should be done to determine if there was any residual physical dependence prior to giving the first dose of naltrexone.

5.5.3.3 Relative criteria

5.5.3.3.1 This group of criteria should help select patients who are likely to stay in the induction period and complete the course of treatment for three months or more. If applied in patient selection, this should improve the retention rate and outcome of the treatment programme.

5.5.3.3.3 Supervision by the significant others of a patient, e.g. non-drug dependent spouse or parents, is necessary. Such supervision should require observation of ingestion of naltrexone and reporting periodically to the therapist.

6.2.1 Methadone maintenance was first introduced into Australia as treatment for heroin dependence in 1969. In the early 1980s, there was widespread concern about the apparent rise in illnesses, crime and death associated with heroin use. In the second half of the 1980s, too, with the increasing concern about the spread of HIV/AIDS amongst injecting drug users, evidence emerged of the useful role methadone treatment could play in harm minimization and reducing the spread of HIV/AIDS amongst the illegal opioid users. Methadone maintenance treatment was endorsed at the launch of the National Campaign Against Drug Abuse in 1985. The Campaign is a major national effort to minimize the harmful effects of drugs - both legal and illegal - on Australian Society, and is overseen by the Ministerial Council on Drug Strategy (MCDS), which comprises Commonwealth, State and Territory Ministers responsible for health and law enforcement. National guidelines for methadone treatment were first endorsed by the Australian Health Ministers’ Conference in 1985 which also accepted harm minimization as the principal aim of national drug policies. In 1993, the Commonwealth, State and Territory Governments agreed that the guidelines should take the form of a national policy. The National Methadone Policy reflects substantial national agreement about the important strategic role of methadone treatment in reducing drug-related harm in Australia. It outlines the objectives of methadone treatment and identifies the key procedures and strategies to be used in providing effective treatment service. In the early 1980s, approximately 3 000 clients used methadone which grew steadily to about 17 000 in 1995.

6.2.2 Currently, State, Territory and Commonwealth Governments as well as clients all contribute to the funding of methadone treatment services although direct service provision is a State/Territory responsibility. Methadone programmes are provided in both public and private health sectors, in specialist and generalist clinics, prisons and community pharmacies in conjunction with public or private programmes. A flexible treatment approach is adopted to meet the needs of different clients.

6.3.1 Methadone maintenance has been used extensively for the rehabilitation of severely addicted persons in Canada for the last 25 years. Approximately 85% of Canada’s methadone treated patients are being treated in British Columbia (BC), with the great majority by physicians in the Greater Vancouver area. This amounts to about 1 500 patients. Methadone is used for those intractable heroin dependent persons who have failed at other treatment methods and are continuing to use intravenous drugs. This patient population is currently not being served by existing drug treatment programmes, having failed at conventional detoxification methods, and end up seeking methadone treatment.

6.3.2 While methadone maintenance treatment has become one of the mainstays of effective harm reduction in this group of severely addicted patients, services available in BC are “low-service types of treatment”, with no regular counselling on site. More comprehensive and better structured programmes are yet to be awaited.

6.4.1 The number of drug users in France is estimated to be between 150 000 and 300 000. About 30 000 persons are receiving some form of substitution e.g. morphine. Unlike US, Australia and UK, the French resistance to methadone has been long lasting. It was not until 1995, after 20 years of a restricted experimental programme of methadone prescription (50 patients authorized) that a legal framework was finally set in place for the authorization of methadone to be delivered to drug users. In 1997, about 5 000 persons were being treated with methadone either at dedicated centres or by general practitioners. The control is very strict, with treatment initiation taking place in a specialized centre, and referring to a general practitioner and a pharmacist at a later stage and allowing a take-home dosage. It appears that the AIDS epidemic in combination with the fact that large groups of drug users were increasingly excluded from medical and social assistance, have paved the way for the new developments : not only substitution programmes, but also needle exchange schemes, low-threshold drop-in centres and crisis night shelters, or in other words, a harm reduction policy.

6.4.2 With the limited data-base available for methadone treatment, it is still too early to draw conclusions from this major change in substitution therapy in France in terms of its impact on risk and harm reduction.

6.5.1 Singapore adopts a “zero tolerance of drugs” philosophy on anti-drug policy. Consumption of drugs in Singapore is in itself an offence. As abusing drugs is against the law in Singapore, drug dependent persons are being treated as criminals and if arrested, they are all sent to compulsory treatment. This is a major deviation from the Hong Kong system in which abusing drugs is not an offence, and drug treatment and rehabilitation is largely voluntary. There is no methadone treatment programme in Singapore that the Working Group can make reference to.

6.6.1 Switzerland is a country with a population of seven million and an estimated 30 000 persons who are addicted to mainly heroin and/or cocaine. The Swiss government pursues a four-pronged strategy to prevent the individually and socially damaging effects of drug misuse. These are repression (criminal prosecution of illicit product, trafficking, possession, etc.), prevention, therapy and harm reduction.

6.6.2 In terms of treatment, unlike drug treatment systems in most other countries, the Swiss drug treatment system is highly resourced with high levels of drug free residential and community treatment as well as high levels of oral methadone treatment. It is estimated that around 13 000 people have enrolled in the methadone substitution programmes. The Swiss government also attaches great importance to scientific research and systematic evaluation of all measures taken to combat the drug problem. An example is the Swiss Scientific Studies of Medically Prescribed Narcotics to Drug Addicts that were conducted in three phases between 1995 and 1998. The narcotics studied and prescribed are intravenous heroin, morphine and methadone. The results of these trials are to be compared to the experiences made with the prescription of oral methadone. The World Health Organization (WHO) Programme on Substance Abuse was invited to undertake an external and separate assessment of the Swiss trials.

6.6.3 The Swiss studies were not able to examine whether improvements in health status or social functioning in the individuals treated were causally related to heroin prescription per se or a result of the impact of the overall treatment programme. Hence, from a rigorous methodological viewpoint, it was not possible to obtain internally valid results with respect to the research question of heroin prescription being causally responsible for improvements in health status or social functioning in the individuals treated.

6.6.4 The external evaluation supported the study conclusions that: (a) it is medically feasible to provide an intravenous heroin treatment programme under highly controlled conditions where the prescribed drug is injected on site, in a manner that is safe, clinically responsible and acceptable to the community; (b) participants reported improvements in health and social functioning and a decrease in criminal behaviour and in reported use of illicit heroin.

6.6.5 There is a need for continued scepticism about the specific benefits of one short-acting opioid over others and there is a need for further studies to establish objectively the differences in the effect of these different opioids.

6.7.1 The primary objective of the Dutch drug policy is to minimize the risks of drug use for the individual drug users, their immediate environment as well as society at large. Dutch policy on “hard” drugs is based on the principles of harm reduction which is aimed at minimizing health risks without solely striving for drug abstinence. Besides harm reduction, supply reduction and demand reduction constitute the other two objectives. The former policy aims at suppressing the supply of drugs by combating illegal, mostly internationally organized drug trafficking, while the latter is realized by prevention activities directed at discouraging drug use by experimenting as well as potential drug users.

6.7.2 In terms of addiction treatment, the Dutch system consists of an elaborate and differentiated network of specialized services, both hospital and clinic based. The in-patient facilities provide treatment focusing on a drug-free existence such as crisis intervention and detoxification with follow-up treatment aiming at overcoming the addiction. A nationwide network of clinics, the CADs (Consultation Bureaus for Alcohol and Drugs) offers care to drug dependent persons on an out-patient basis, including methadone substitute, counselling, group and psycho-therapy. Moreover, many institutes provide “low threshold” socially oriented care such as street corner work and daytime shelters for drug addicted prostitutes. Regionally, too, many in-patient and out-patient organizations operate in close co-operation to devise programmes to handle specific problems of target groups.

6.7.3 One of the key elements of assistance to drug dependent persons in the Netherlands is the free supply of methadone. The estimated number of drug dependent persons receiving methadone is 14 000 (out of a population of approximately 25 000 heroin dependent persons). Of these, over three quarters were on maintenance therapy. They are managed mostly in the CADs. It is also possible to receive methadone at detention houses, prisons or at police offices. In some cities, physicians also prescribe methadone, particularly to older relatively well functioning drug dependent persons.

6.8.1 In the US before 1914, it was relatively common for private physicians to treat opiate-dependent patients in their practices by prescribing narcotic medications. This was viewed as problematic by officials charged with enforcing the law and as a result, these physicians were indicted and prosecuted. Some local governments then started to set up formal morphine clinics for treating opiate addition but were eventually closed for similar reasons. For the next 50 years, opiate addiction was basically managed by the criminal justice system and two Federal public health hospitals. The relapse rate for opiate use from this approach was close to 100%. During the 1960s, opiate use reached epidemic proportions in the US, with significant increases in crime, deaths from opiate overdose, and number of younger people engaging in opiate addiction lifestyles. This had led to a search for more effective and innovative methods of treatment, resulting in the emergence of drug-free therapeutic communities and the use of methadone to maintain those with opiate dependence. In 1964, maintenance treatment with methadone was started in New York. Its successful outcome led to expansion of the programme to become the major public health initiative for the treatment of heroin addiction. In the US, methadone maintenance treatment has typically been delivered by clinics which dispense oral preparations of methadone for consumption under supervision. With the emergence of the AIDS epidemic, the role of methadone maintenance in reducing the spread of the disease in the vulnerable population has been duly recognized.

6.8.2 While approximately 125 000 of the estimated 800 000 opiate-dependent persons in the US now are receiving methadone maintenance treatment at any point in time, strict Federal and State regulations have restricted the number of treatment providers and patient access. Some of these regulations are driven by disproportionate concerns about methadone diversion and provision of the drug without any other associated social services. Currently, the Centre for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration (SAMHSA) is responsible for the methadone treatment programmes. Together with the Health Care Financing Administration, they provide funding for the programmes through block grants allocated to State governments and through the Federal-State medical programme for the needy. While the Department of Health and Human Services (DHHS) does not directly operate these programmes, it regulates them through the Food and Drug Administration (FDA). Very stringent treatment standards and regulations are laid down. In some States, there is even total prohibition of use. It could be said that methadone treatment has been the most regulated of the treatment interventions. In some other cases, lack of funding has compromised the accessibility of the programme. In New York, for example, there is always a waiting list for admission.

6.8.3 It is noted, however, that SAMHSA through CSAT and DHHS, recognizing methadone maintenance as a necessary and the most effective approach currently available for persons addicted to opioids, are undertaking strategies to improve the service, in particular targeting towards regulatory reforms. Since the 1990s, various committees and expert panels have been set up for this purpose. In November 1997, an Expert Committee under the National Institutes of Health (NIH) issued a report, the Consensus Development Statement, calling for easing federal restrictions on methadone and advocating, amongst others, broader access to treatment for those addicted to opiates and improved training of health professionals in the diagnosis and treatment of this medical disorder. At the same time, the White House Office of National Drug Control Policy (ONDCP), which oversees federal efforts concerning illegal drug trafficking and abuse, has endorsed the NIH Committee’s call for removing cumbersome barriers to methadone treatment of heroin dependent persons, and reaffirmed methadone as an important part of the national treatment strategy.

6.8.4 Currently, FDA and SAMHSA are proposing a change to the methadone regulations. It is anticipated that the change, when approved as a final policy, will have the effect of improving access to quality treatment for persons addicted to heroin and other opioid drugs. The goals are to make Federal oversight more effective, to permit greater flexibility in medical and clinical practice, and to reduce variability in the quality of services provided.

6.9.1 Methadone is widely used as a treatment for drug addiction in the UK, constituting over 90% of all opioid prescriptions dispensed to drug misusers. Traditionally, methadone maintenance treatment have been delivered in specialist drug clinics, but more recently a substantial proportion of this prescribing is undertaken by general practitioners. In addition, there has been an increase in more structured programmes operating on a “three-tier” model of service provision. Here, specialist drug clinic treatment services manage the most complex clients and are most likely to provide on-site supervision. A community drug agency with less complex clients might make use of supervised off-site dispensing, for example, at a community pharmacy; and general practitioners are most likely to manage stable patients who are suitable for off-site dispensing without supervision.

6.9.2 In 1994, the Task Force to Review Services for Drug Misusers looked at, inter alia, specific interventions and evidence for their efficacy including methadone maintenance. In 1996, it concluded that “The international evidence suggests that out-patient methadone maintenance programmes which incorporate psychosocial interventions can enable clients to remain stable and are effective in reducing misuse, improving health and reducing criminal activity. These programmes therefore form a significant component of drug misuse services”.

6.9.3 Concurrently, the effectiveness of different treatment regimes has also been explored in the National Treatment Outcome Research Study (NTORS), the largest prospective longitudinal cohort study of treatment outcome for drug misusers ever conducted in the UK. Intake of clients was started in 1995. The report at two years has also indicated that there are substantial health and social benefits to individuals receiving treatment whether in the form of methadone maintenance in the community or in a residential rehabilitation Unit. NTROS suggests that drug treatment is very cost-effective, in terms of generating savings to the Criminal Justice System.

6.9.4 In the United Kingdom, a study was conducted by the Forensic Psychiatry Research Unit of the St. Bartholomew’s Hospital in 1996 with a sample of 81 referrals to a methadone treatment programme based at Hackney, East London. The key aims of the study were to identify whether methadone treatment reduces opiate and other drug use and whether methadone treatment reduces self-reported criminal activity and earnings from crime.

6.9.5 The study confirmed the effectiveness of methadone treatment programme in reducing both opiate misuse and a range of criminal behaviours at 6 months. It also confirmed the significant reduction in expenditure on drugs, injecting behaviour, and high-risk behaviours involving sharing of syringes and needles amongst heroin dependent persons. The study reveals that though there was no change in a range of other illicit drugs misused, there was no increase in the use of other drugs and subjects had not substituted these for heroin. Significant increase in legally obtained income was found during the treatment phase also reflected that subjects had found work. Amongst others, the study also revealed that criminal activities such as burglaries, theft and drug-dealing amongst patients though little were greatly reduced, changes was observed in other criminal behaviours such as involving in sex work, muggings, etc. The study concluded that methadone treatment had its greatest impact on individuals who were heavily involved in crime, and that retention in the programme was a highly important factor for reduction in illicit use of opiates and reduction in criminal activities.

6.10.1 New Zealand has a predominantly publicly funded health service. Here, the New Zealand Government acts as a consumer’s agent through the Health Funding Authority and funds health (both primary and specialist) and disability services on behalf of consumers. The Government requires the Health Funding Authority to consult with the community on what health and disability services are funded within the resources available to ensure community values are reflected in the decisions made. Treatment for opioid dependence including methadone and other opioid drugs has been regarded as a specialist service and the Misuse of Drugs Act 1975 requires special approval for medical practitioners to be permitted to prescribe controlled drugs in order to treat dependence. Although there has not been a single “programme” as such, methadone treatment has been provided mainly by specialist alcohol and drug clinics or services, generally in accordance with a National Protocol, and is generally publicly funded.

6.10.2 In recent years, growth in methadone treatment services has not been sufficient to meet rising demand. The Ministry of Health in 1996 has reviewed the situation and endorsed an increase in methadone services in the primary sector (provided by general practitioners) from 20% to 50%.

6.11.1 The use of opioid substitution in the management of heroin and other forms of opioid dependence has been a controversial form of treatment that has been subject to extensive evaluation. According to the 30^th Expert Committee on Drug Dependence Report (WHO 1998), the main objectives of treatment of opioid dependence are similar to other forms of substance use dependence treatment and they are :

6.11.2 Additional objectives of treatment include a reduction in criminal and antisocial behaviour, a decrease in users’ dependence on public (welfare) support, and an increase in productive legitimate activities. Since 1970 methadone maintenance treatment has grown to become the dominant form of opioid substitution treatment globally (WHO 1998). The large body of data available on its safety and efficacy has resulted in a consensus within the medical community that it is a valuable treatment modality for many heroin dependent persons. A number of randomized controlled trials and numerous observational studies of methadone maintenance have also demonstrated reductions in illicit opioid use, injecting and criminal behaviour and improvements in physical psychological and social well being (WHO 1998).

6.12.1 As noted from the experiences of the countries quoted, although different countries apply methadone in accordance with their own national drug policies and implement methadone maintenance programme with varying degrees of differences, the importance and effective role methadone plays in these countries are similar.

7.1.1 The importance of injecting drug use as a route of HIV transmission is well-recognized. Explosive increase in HIV infection amongst drug users has continuously been reported in several places, including the Mainland and other countries of South East Asia. Due to a variety of factors, Hong Kong is fortunate enough to have enjoyed a low HIV infection rate associated with injecting drug use in the past.

7.1.2 The chance for a large and quick rise in HIV prevalence of drug users is always there when there is presence of HIV-related risk behaviours, in particular needle-sharing for drug injection. The situation can be very dynamic and change rapidly. There was evidence to suggest that HIV infection amongst drug users in Hong Kong has increased, as inferring from the reported HIV/AIDS statistics as well as surveillance through blood testing and unlinked anonymous screening of urine. The behavioural risks add to the worry that spread can be rapid as HIV has been introduced into the drug-taking community.

7.1.3 In Hong Kong, the Special Preventive Programme of the Department of Health closely monitors the trend of HIV in Hong Kong. To understand the HIV situation and pattern of injecting behaviours in drug users in Hong Kong, four areas are being studied :

7.2.1 From 1984 to the end of December 1999, a total of 1 359 HIV cases had been reported to the Department of Health. Amongst them, 433 were known to have progressed to AIDS. There was a steady increase in the number of newly diagnosed HIV infection over the years through the voluntary reporting system.

7.2.2 Concerning the demographic characteristics, males are still the predominantly affected ones (83.7% of total), although female infections were also increasing. Male to female ratio of the newly reported cases decreased from 6:1 in 1994 to 3.6:1 in 1999. Chinese accounted for nearly 70% of the infections.

7.2.3 Sexual contact remained to be the most important mode of transmission, accounting for 82% of cumulative total, with heterosexual to homo-/bisexual contact ratio of about 2 to 1. Ten mother-to-child (perinatal) infections were reported so far.

7.2.4 Cumulatively, 23(1.7%) of the infections were related to injecting drug use. 21 were males and 15 were ethnic Chinese. Seven had progressed to AIDS and three of them had died. The number of cases reported varied between one to three before the year 1998. In 1999, however, six cases were injecting drug users (IDU).

7.3.2.1 Unlinked anonymous screening (UAS) first started in methadone clinics in 1992, and was later extended to a number of in-patient drug treatment centres.

7.3.2.2 The number of HIV positive samples in methadone attendants was 6 out of the 2 838 specimens collected in 1998, giving a rate of 0.21%. This was the highest rate that has ever been recorded amongst local drug dependent persons. The overall prevalence was 0.11% in 1999. The HIV prevalence in urine samples from patients recruited from in-patient drug treatment centres also rose from 0.13% in 1998 to 0.18% in 1999.

Behavioural surveillance on new admissions to the methadone treatment programme has started since 1990 and in SARDA’s Shek Kwu Chau (SKC) in-patient drug treatment centre since 1991. The main focus is on two HIV related risk indicators: rate of injecting drug use and needle-sharing rate. The latter is further categorized into ever-needle sharers and current-needle-sharers. The interviews were conducted by the medical doctors using a standardized checklist in the consultation setting.

7.4.1 New admissions to MTP

7.4.1.1 The methadone programme has between 1 000 to 1 900 new admissions each year. The mean age of the new attendees is about 27 and majority of them are male i.e. 79% - 88%. As at 1998, 20% had reported that they were using injection as the main route of taking heroin at around the time of interview, and 80.2% said they used disposable needles and syringes every time. Amongst those injecting drug users, 6% reported that they had injected within the preceding one month. Regarding needle-sharing behaviour, about 12% were ever needle sharers in 1998 and the figure varied from 5.1% to 12.6% during the period of 1994 to 1998. As for the needle sharing rate within the four weeks prior to interview, it fluctuated from 1.4% to 5.3%.

7.4.2 Admissions to SKC drug treatment centre

7.4.2.1 The number of new admissions to SKC Centre was around 2 000 per year from 1994 to 1998. The mean age of the patients was higher (36 - 40) and all of them were male. About 75% of the admissions were injecting drug users in 1998. Less than 8% was reported to be ever-needle sharers and the needle sharing rate within four weeks prior to interview dropped from 3.4% to 1.4% from 1994 to 1998.

7.4.3 Reported cases to the Central Registry of Drug Abuse (CRDA)

7.4.3.1 From 1989 to 1998, the annual number of reported drug dependent persons to the CRDA ranged from some 12 500 to 17 000 with about 1 000 - 3 000 new cases for the specified year. About 20% of the newly reported drug dependent persons used injection for taking heroin in the last four weeks; the figure remained relatively stable in the past nine years. Seemingly, the proportion of previously reported persons injecting heroin in the last four weeks dropped slightly in 1997 and 1998.

7.5.1 From December 1999 to February 2000, clients attending 21 methadone clinics were randomly selected to participate in a survey. Objectives of the study were to study the HIV prevalence, examine HIV-related risk behaviours, and explore the role of MTP in HIV prevention. Medical doctors on-duty conducted interview and counselling for clients. Voluntary HIV testing was done with the consent of the clients. A total of 690 (73.6%) clients were successfully interviewed over an eight-week period of this cross-sectional study, amongst 937 clients who were invited to participate. The results showed that there was positive response regarding the usefulness of the programme for HIV prevention, in terms of increasing knowledge, reducing drug injection and needle-sharing. None of the 380 blood samples collected was tested HIV antibody positive.

7.5.2 Though the absolute number of infections was still small, HIV infection amongst drug users in Hong Kong has shown an increase, as inferring from the reported HIV/AIDS statistics as well as surveillance by unlinked anonymous screening and voluntary blood testing at methadone clinics and other drug treatment and rehabilitation centres. HIV prevalence of drug users in methadone clinics detected via UAS was 0.21% (1998) and 0.11% (1999) while the prevalence was found to be 0.34% (1998) and 0.4% (1999) detected through voluntary blood testing in drug treatment centers which mainly consisted of methadone clinics and a few in-patient drug treatment centers.

7.5.3 Vulnerability of local drug users in contracting HIV is also evident from the behavioural data of drug injection and needle-sharing. The presence of risk drug-taking behaviours in terms of HIV transmission remained consistent as noted from the sources of methadone clinics, SKC Drug Treatment and Rehabilitation Service and CRDA. Future potential for take-off of HIV infections in the drug users cannot be underestimated.

7.5.4 The survey showed that methadone clinics have proved to be an invaluable channel for undertaking public health surveillance of HIV situation amongst the drug users in Hong Kong. Besides seroprevalence data from unlinked anonymous screening and voluntary testing, it also enabled data of risk behaviours to be collected regularly and consistently for monitoring. Surveillance is an integral part of an effective AIDS programme.

7.5.5 The survey also showed that there was improvement in the knowledge on HIV/AIDS, as well as diminished risk behaviours in drug users after attending methadone clinics. This ecohed the findings of overseas studies on the protective effect of methadone treatment programme for HIV infection in drug users and hence the larger community. The Working Group considered that the historical low HIV prevalence amongst drug users in Hong Kong has been contributed by the early implementation of territory-wide MTP in the 1970s and its wide catchment in the locality.

7.6.1 The Working Group recognized that the purpose of MTP is not to screen out HIV patients but to serve as an important tool in HIV surveillance and prevention. In view of the increasing trend of drug dependent persons contracting HIV/AIDS, the Working Group considered it important that the interface between intravenous drug use and HIV/AIDS prevention be given more focus and joint strategies be formulated to further combat the problems of needle-sharing and spread of HIV.

7.6.2 Apart from the continuous, on-going efforts to strengthen communication between ACAN and the Advisory Council on AIDS, the Working Group considered that MTP should continue and enhance its important and effective role in HIV surveillance and prevention through encouraging more voluntary blood testing and enhancing health education and prevention programmes. In this regard, due attention should be paid to the following areas :

7.6.3 In addition, the public as well as patients should be educated on the harm reduction role of MTP in HIV/AIDS prevention thorough health publicity and education.

8.2.1 The main emphasis of MTP is its out-patient maintenance component which is recognized worldwide as an effective substitution therapy for opioid addiction. One clear merit of the current programme is its open door policy where no entry barrier is set for those who wish to enroll, its simple procedures and zero waiting time. With a set of long-standing, workable admission criteria and guidelines, a network of 21 clinics covering various regions of the territory and supervision by medical practitioners and trained AMS staff, MTP indeed provides a readily accessible and legal alternative to continued illicit opiate drug use. From the survey conducted in support of the Review, it was evident that in general, satisfaction with the service of methadone clinics was high (around 80% as recorded in paragraph 3.5.1.3.1). The survey also confirmed that most methadone patients were satisfied with the operation of methadone clinics, in particular their degree of freedom, facilities, staff attitude and waiting time.

8.2.2 Furthermore, from the MTP survey, over half of the methadone patients (58.0%) reported that they had not abused heroin during the past four weeks of the time of enumeration (3.5.2.5.1). Although not all MTP patients stop abusing heroin after enumeration, the programme nevertheless helps over half of the patients achieve abstinence from heroin. This has helped reduce instances of poly-drug abuse and drug overdose. Though some methadone patients still expressed dissatisfaction on some detailed aspects of MTP operation, such as opening hours of clinics, dosage, access to and environment within the clinics, the majority view supported that MTP was a readily accessible, legal, medically safe and effective alternative to continued illicit opiate drug use. Having explored some alternative drugs which allegedly might replace methadone, the Working Group affirmed that methadone was still, by far, an effective drug for maintenance with the least side-effects.

8.2.3 In spite of the above, the Working Group considered that the most desirable alternative to continued illicit opiate drug use was of course absolute abstinence from drugs. Given the advent of science and technology, it will be prudent for the Administration to continue to keep in view the emergence of new drugs or improvement to existing ones which might out-perform methadone in substitution therapy in due course.

8.3.1 The meaning of “maintenance” is to ensure that the patients on the programme are adequately maintained on methadone to prevent the withdrawal symptoms of opioids so that they can engage in normal daily activities. The existing out-patient mode of MTP allows patients to stay with their families, work or attend school as usual and continue to perform their daily activities. The efficacy of methadone lasts for 24 to 36 hours so that one clinic attendance by patient per day is sufficient. All these allow the greatest freedom for patients under MTP and are what make MTP a popular therapy amongst them. Popularity of the programme is in part reflected in the consistently high registration under MTP : as at November 2000, such registration amounted to 9 500, representing 65% of the total admissions to all drug treatment programmes in Hong Kong.

8.3.2 Although a variety of factors may affect whether a person can lead a normal life, and whether one can be gainfully employed, e.g. one’s resolve and ability to reintegrate into the society, the economic condition and employment opportunities at the time, one’s vocational and inter-personal skills, etc, data of the MTP survey confirmed that MTP contributes positively to patients leading a normal and economically productive life. According to the survey, 55.9% of methadone patients were employed, either as full-time workers or casual/part-time workers at the time of the survey. This represented an increase of 4.6% in the employment of such patients compared to the time of their first admission to MTP (3.5.2.4.1).

Moreover, the survey also tackled whether a patient’s life was more “normal” during/after MTP by enquiring into their spirit and social behaviour. The majority (74.0%) of the patients reported that they had improved in spirit after receiving methadone treatment (3.5.2.1.1). After joining MTP, about 35.5% of the patients also reported that they had made more frequent contacts with their non-drug dependent friends, thereby building/reinstating their social network with the non-drug dependent circles (3.5.2.3.1).

8.3.3 The above does not imply that there is no room for improving the assistance to be rendered to patients in order to help the latter lead a normal and economically productive life. As mentioned in Chapter II of this Report, the current systems of patient assessment could be conducted in a more structured, in-depth and comprehensive manner, thereby yielding data for more personalized referral or support services, such as appropriate employment services, etc.

8.4.1 Although the prevalence of crime in a society and crime rate are affected by a variety of factors, over 50% of the methadone patients surveyed indicated that people committed fewer illegal acts such as thefts and robberies after joining MTP (3.5.2.7.1). In addition, an association between the average daily attendance of MTP and certain crime-related phenomena could be observed. For example, more methadone patients turn up for treatment when there is an increase in the price of heroin or a decrease in reported crimes of minor narcotics offences. Besides, there is also a negative association between the average daily attendance rate and the reported crime rate of thefts (3.5.2.7.2).

8.4.2 As to whether MTP helps reduce antisocial behaviour, the survey conducted in support of this Review showed that there was improvement in the relationship between MTP patients and their families. Over 50% of the patients surveyed had improved relationship with their family members after receiving methadone treatment. Such improvement was particularly significant amongst young patients (3.5.2.2.1). Moreover, a higher percentage (55.5%) of the patients who had ever received counselling service from SARDA were found to have improved relationship with their family members after receiving methadone treatment, compared to those who had never received counselling service from SARDA (3.5.2.2.2). As mentioned in 3.5.2.3.1, after receiving methadone treatment, about 35.5% of the methadone patients said that they had made more frequent contacts with non-drug dependent friends.

8.4.3 Having said that, however, the Working Group considered that MTP could further enhance its capability to fulfil the objective of minimising criminal and antisocial behaviour by strengthening counselling and support services under the programme. In due course, further in-depth research focusing specifically on the effectiveness of MTP in reducing crime should be conducted.

8.5.1 The protective effect of MTP for HIV infection amongst drug users as well as the larger community has been confirmed both locally and overseas. The historical low HIV prevalence amongst drug users in Hong Kong, compared to high prevalence in the neighbouring countries or territories of Hong Kong, has no doubt been contributed in part by the early implementation of MTP in the 1970s. Over half of the methadone patients surveyed reported that they had not abused heroin during the past four weeks of the time of enumeration (3.5.2.5.1). This implied that they had abstained from using needles in the same period. Even amongst patients who still abused heroin during the past four weeks of the time of enumeration, less than 5% reported that they had shared syringes with others (3.5.2.6.1). This indicated that MTP had directly lowered the chance of blood-borne disease transmissions amongst the drug-abusing population.

8.5.2 The survey also showed that education amongst the MTP patient population on prevention of blood-borne diseases by avoiding/reducing needle-sharing has borne fruit. From the survey, high percentages of patients reported that they knew that AIDS (90.8%), hepatitis (43.2%) and tetanus (18.7%) might be contracted through the use of shared or unsterilized syringes for injection, compared to the time of their first admission to MTP (AIDS (79.4%), hepatitis (27.6%) and tetanus (15.1%) (3.5.2.6.2). Nevertheless, the Working Group is of the view that given the comprehensive catchment of heroin dependent persons, the large patronage of MTP, and the fact that such patronage comprises essentially persons who are extremely prone to using/sharing needles, it remains important to strengthen MTP’s functions in surveillance and prevention of HIV and other blood-borne diseases, and in this connection, consideration should be given to further using MTP clinics as a base for public health education, especially in relation to blood-borne diseases.

8.6.1 The current number, location and opening hours of methadone clinics, coupled with an open door policy and zero waiting time for patients, mean that MTP already fulfils this objective. The Department of Health will keep the overall operation of methadone clinics under constant review with a view to further improving services for patients.

8.6.2 In spite of the above, the Working Group considered it important to enhance public understanding of MTP through publicity and education. This will help correct the misconceptions about methadone as a drug and the objective of MTP as a treatment modality, thereby enhancing public acceptance of MTP and encouraging more drug dependent persons to come forward for treatment.

8.7.1 Traditionally, detoxification is not the mainstay of MTP. Amongst the 9 500 patients registered with MTP as at November 2000, about 1.5% were receiving detoxification service. In the past four years (1996 to 1999), the average success rate of detoxification by methadone was about 20%. In the past 21 years, however, there was a gradual increase in the number of patients enrolled in the detoxification programme under MTP. This shows that detoxification using methadone is increasingly acceptable and adopted by patients. It is also worthwhile to note that the survey in support of the Review revealed that at the outset, the main reason of the majority of methadone patients (55%) for joining MTP was detoxification (3.5.1.2.1). A great majority (88.9%) of the methadone patients interviewed reported that they had ever considered using methadone for detoxification (3.5.1.6.1). These indicated that drug dependent persons did have expectations on MTP in helping them to detoxify.

8.7.2 That said, under an out-patient mode of MTP, it is appreciated that detoxification is not easy to achieve, not to mention the continuous provision of aftercare service. To address this inadequacy, therefore, the Working Group is of the view that consideration should be given to strengthening support services for patients, and using naltrexone to assist in relapse prevention amongst detoxified patients. A more in-depth research study on the use of naltrexone should first be conducted prior to any formal application of the drug under MTP.

8.8.1 Amongst the various drug treatment and rehabilitation modalities in Hong Kong, MTP engages the most number of drug dependent persons at a time. Its voluntary, out-patient nature and well-established territory-wide clinic network make the programme one of the most convenient and accessible drug treatment programmes in Hong Kong. From the above analyses and recognizing that drug addiction is a chronic relapsing illness, the current MTP fulfils its declared objectives and is effective in helping drug dependent persons to sustain their employment and social life, as well as helping society to reduce instances of drug overdose, drug-related death and even spread of blood-borne diseases. The Review also confirmed that MTP should continue to comprise maintenance and detoxification elements so as to offer choice, though the mainstay of the programme will remain a substitution therapy with a “harm reduction” objective. The Review affirms MTP’s open-door policy as it recognized that it worked well for those who had a need for the service.

8.8.2 Balancing the current operational mode of MTP which is considered to be generally efficient, and the room MTP presents itself for enhanced productivity, the Working Group recognized that MTP should move towards a more knowledge-based approach to service provision. While intensifying care for individual patients would entail allocation of additional resources, the Working Group considered that the existing support services of MTP could be improved through, e.g. increased use of peer counsellors, formation of patient mutual support groups, etc. In connection with this, a clear set of outcome indicators for different MTP components can be developed and training of staff could be enhanced. To address the weaknesses of out-patient detoxification which, in the main, are the lack of intensity and relatively weak supervision and peer support, naltrexone should be considered as a drug to assist relapse prevention. At the same time, public education on MTP should be considered in order to enhance the community’s acceptance of the programme and in this connection, acceptance of the patronage of the programme.

8.8.3 Taking advantage of the large catchment of drug dependent persons under MTP, enhancement of referral services and coordination between MTP clinics and other drug treatment and rehabilitation agencies should facilitate patient management. With this development, the focal point of MTP should still remain on service recipients. Strengthened support services under MTP should, as far as practicable, contribute to a more comprehensive approach of service provision with emphasis on continuity of care for service recipients.

8.8.4 The Working Group considered that given the effectiveness of MTP in assisting in prevention of HIV and other blood-borne diseases, and the increased emphasis on such prevention in today’s community, the importance of HIV/blood borne diseases prevention as a MTP objective can be enhanced. The six declared objectives of MTP as recorded in 2.2.1 should also be slightly altered to reflect increased emphasis on support elements.

(P.20)

9.2.4 Following the assessment, individual treatment plans for patients should be developed. Such plans may include, amongst others –

9.2.5 Patients should be involved in developing their personal treatment plans.

(P.21)

9.2.6 A structured patient reassessment mechanism should be put in place with a strengthened/improved protocol to allow for more regular and vigorous reviews of patients’ treatment plans. Such reassessment should also be used as a tool to facilitate placement of patients to suitable treatment modality if necessary. This would also help sustain patient’s motivation to make progress in the programme he has enrolled.

(P.98)

(P.98)

9.4.3 Enhanced publicity and education to encourage voluntary HIV testing by patients of MTP should be considered.

(P.98)

(P.22, P.36)

9.5.2 With improved physical setting, methadone clinics should be used as a focal point for the delivery of additional activities such as :

(P.22, P.36)

9.5.3 A staff in each MTP clinic should be appointed as a liaison or line worker to facilitate delivery of services to patients in clinic.

(P.22)

(P.23)

9.6.1 Besides treatment setting, the following aspects of the operation on MTP should be strengthened :

(P.26, P.36)

9.7.1 Two distinct sets of clear, measurable outcome indicators should be developed for maintenance and detoxification programmes respectively under MTP. The following, however, may be common in both sets of indicators :

(P.58)

9.9.1 In respect of public education and publicity, due attention should be paid to the following areas :

Alternative/supplementary drugs

(P.78)

9.10.7 In due course, more in-depth research on the effectiveness of MTP in helping to reduce crime should be conducted.

10.1.1 The Working Group considered that while some of the recommendations set out in Chapter IX could be implemented with internal redeployment of resources and support from the Beat Drugs Fund, some would only be implemented with the support from Government’s recurrent Resource Allocation Exercise and capital bids.

10.1.2 The Working Group proposed that improvements in the following areas should be effected with redeployment of existing resources :

10.1.3 Improvements in the following areas should be supported by the Beat Drugs Fund or other charitable funds :

10.1.4 Improvements in the following areas should be supported by Government’s recurrent Resource Allocation Exercise :

10.1.5 Improvements in the following areas should be supported by Government’s capital bids :-

10.2.1 Following ACAN’s endorsement of this Report and the recommendations therein, ACAN and its sub-committees, including the Treatment and Rehabilitation Sub-committee, Preventive Education and Publicity Sub-committee and Research Sub-committee, should follow up on the implementation of the recommendations. Where appropriate, special monitoring groups should be formed to keep in view the progress of implementing the more complex recommendations such as research on naltrexone, etc.

10.2.2 To support ACAN’s work on the above, the Narcotics Division, Department of Health and relevant agencies such as the Hospital Authority and SARDA should work out feasible action plans with appropriate timeframes in respect of the recommendations set out in Chapter IX.